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

  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)

openEHR-EHR-OBSERVATION.apgar.v1

openEHR-EHR-OBSERVATION.apgar.v1
Description

openEHR-EHR-OBSERVATION.apgar.v1

Hartslag
Description

Opnemen van de hartslag van het kind.

Data type

integer

Alias
UMLS CUI [1]
C0018810
Ademhalingsinspanning
Description

Observatie van de ademhalingsinspanning van het kind.

Data type

integer

Alias
UMLS CUI [1]
C0425466
Spiertonus
Description

Observatie van de spiertonus van het kind.

Data type

integer

Alias
UMLS CUI [1]
C0026841
Reactie op prikkels
Description

Observatie van de reactie van het kind op een irritante prikkeling, bijvoorbeeld het uitzuigen van de keel en neus met een zachte rubberen katheter.

Data type

text

Alias
UMLS CUI [1]
C1317677
Huidskleur
Description

Observatie van de huidskleur van het kind.

Data type

integer

Alias
UMLS CUI [1]
C0475704
Apgar score
Description

Score die bereikt wordt door beoordeling van ademhalingsinspanning, hartslag, reflexen, spiertonus en kleur.

Data type

integer

Alias
UMLS CUI [1]
C0003533
1 minuut
Description

Apgar score 1 minuut na de geboorte.

Data type

integer

Alias
UMLS CUI [1]
C0426279
2 minuten
Description

Apgar score 2 minuten na de geboorte.

Data type

integer

Alias
UMLS CUI [1]
C0489254
3 minuten
Description

Apgar score 3 minuten na de geboorte.

Data type

integer

Alias
UMLS CUI [1]
C0003533
5 minuten
Description

Apgar score 5 minuten na de geboorte.

Data type

integer

Alias
UMLS CUI [1]
C0489255
10 minuten
Description

Apgar score 10 minuten na de geboorte.

Data type

integer

Alias
UMLS CUI [1]
C0003533
Any event
Description

Apgar score op elk toe te voegen tijdstip, indien nodig

Data type

integer

Alias
UMLS CUI [1]
C0003533
Opmerkingen over de meting
Description

Opmerkingen over de meting van de Apgar score.

Data type

text

Alias
UMLS CUI [1]
C1317574
Extension
Description

Extension

Data type

text

Alias
UMLS CUI [1]
C1546922

Similar models

openEHR-EHR-OBSERVATION.apgar.v1

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item
Hartslag
integer
C0018810 (UMLS CUI [1])
Code List
Hartslag
CL Item
Afwezig (0)
CL Item
<100 slagen per minuut (1)
CL Item
≥100 slagen per minuut (2)
Item
Ademhalingsinspanning
integer
C0425466 (UMLS CUI [1])
Code List
Ademhalingsinspanning
CL Item
Afwezig (0)
CL Item
Matig of onregelmatig (1)
CL Item
Normaal (2)
Item
Spiertonus
integer
C0026841 (UMLS CUI [1])
Code List
Spiertonus
CL Item
Slap (0)
CL Item
Verminderde tonus (1)
CL Item
Normale tonus (2)
Item
Reactie op prikkels
text
C1317677 (UMLS CUI [1])
Code List
Reactie op prikkels
CL Item
Geen reactie (0)
CL Item
Verminderde reactie (1)
CL Item
Normale reactie (2)
Item
Huidskleur
integer
C0475704 (UMLS CUI [1])
Code List
Huidskleur
CL Item
Helemaal blauw (0)
CL Item
Lichaam is roze, extremiteiten blauw (1)
CL Item
Helemaal roze (2)
Apgar score
Item
Apgar score
integer
C0003533 (UMLS CUI [1])
Apgar score at 1 minute
Item
1 minuut
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
Any event
integer
C0003533 (UMLS CUI [1])
Notes on measurement
Item
Opmerkingen over de meting
text
C1317574 (UMLS CUI [1])
Extension
Item
text
C1546922 (UMLS CUI [1])

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