ID

23645

Beskrivning

Use to record the presence or absence of a pulse or heart beat. In practice, the terms 'heart rate' and 'pulse rate' are often used interchangeably, although they may be measured at different body sites. This archetype allows either term to be used when the measurement site is not specified, to suit clinician preferences. Use to record the measurement of the pulse rate, or heart rate, observations about the associated pattern and character, and clinical interpretation of the findings. Measurements such as the maximum pulse or heart rate over an interval of time can be recorded using 'Maximum' event. Others point-in-time or interval events may be specified within a template or at run-time. In development of this archetype, there has been some tension around representation of the regularity of the pulse or heart beat. This archetype represents the relevant data points separately: firstly establishing 'Regular' vs 'Irregular' and then, if 'Irregular', further options of 'Regularly irregular' and 'Irregularly irregular'. In practice, clinical systems could offer users a combination of the values from the 'Regular?' and 'Irregular type' - for example, 'Regular', 'Regularly irregular' and 'Irregularly irregular' drawn from these two data elements. Data could be recorded against both data elements with the assumption that if one of the irregular types are selected, then the 'Irregular' value in the 'Regular?' data element is also automatically selected. In certain situations it is important to be very specific so that a rate observed at a peripheral body site, such as the radial artery, can be differentiated from the rate of the heart. To record a pulse deficit, record the measurements of the mechanical heart rate and a peripheral pulse rate in two instances of this archetype - the difference between these measurments is the pulse deficit. The actual pulse deficit will be recorded in a separate OBSERVATION archetype.

Nyckelord

  1. 2017-07-10 2017-07-10 - Martin Dugas
  2. 2017-07-10 2017-07-10 - Martin Dugas
Uppladdad den

10 juli 2017

DOI

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Licens

Creative Commons BY-NC 3.0

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Pulse (EHR Archetype)

openEHR-EHR-OBSERVATION.pulse.v1

  1. StudyEvent: openEHR-EHR-OBSERVATION.pulse.v1
    1. openEHR-EHR-OBSERVATION.pulse.v1
openEHR-EHR-OBSERVATION.pulse.v1.xml
Beskrivning

openEHR-EHR-OBSERVATION.pulse.v1.xml

Pulse/Heart beat
Beskrivning

Record details about the rate and associated attributes for a pulse or heart beat.

Datatyp

text

structure
Beskrivning

@ internal @

Datatyp

text

history
Beskrivning

@ internal @

Datatyp

text

Any event
Beskrivning

Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.

Datatyp

text

Rate
Beskrivning

The rate, measured in beats per minute.

Datatyp

text

Regular?
Beskrivning

Is the pulse or heart beat regular?

Datatyp

text

List
Beskrivning

@ internal @

Datatyp

text

List
Beskrivning

@ internal @

Datatyp

text

Position
Beskrivning

The body position of the subject during the observation.

Datatyp

text

Presence
Beskrivning

Presence of a pulse or heart beat.

Datatyp

text

Device
Beskrivning

Details about the device used to measure the pulse rate or heart rate.

Datatyp

text

Exertion
Beskrivning

Details about physical exertion being undertaken during the examination.

Datatyp

text

Confounding factors
Beskrivning

Narrative description about any incidental factors that may affect interpretation of the physical findings.

Datatyp

text

Method
Beskrivning

Method used to observe the pulse or heart beat.

Datatyp

text

Clinical description
Beskrivning

Narrative description about the pulse or heart beat.

Datatyp

text

Clinical interpretation
Beskrivning

Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm.

Datatyp

text

Character
Beskrivning

Description of the character of the pulse or heart beat.

Datatyp

text

Maximum
Beskrivning

Maximum pulse rate or heart rate observed during a period of exertion.

Datatyp

text

Body site
Beskrivning

Body site where the pulse or heart beat were observed.

Datatyp

text

Irregular type
Beskrivning

More specific pattern of an irregular pulse or heart beat.

Datatyp

text

Extension
Beskrivning

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

Datatyp

text

Comment
Beskrivning

Additional narrative about the pulse or heart beat findings not captured in other fields.

Datatyp

text

Similar models

openEHR-EHR-OBSERVATION.pulse.v1

  1. StudyEvent: openEHR-EHR-OBSERVATION.pulse.v1
    1. openEHR-EHR-OBSERVATION.pulse.v1
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Pulse/Heart beat
Item
Pulse/Heart beat
text
structure
Item
structure
text
history
Item
history
text
Any event
Item
Any event
text
Item
Rate
text
Code List
Rate
CL Item
Pulse Rate (1)
CL Item
Heart Rate (2)
Item
Regular?
text
Code List
Regular?
CL Item
Regular (1)
CL Item
Irregular (2)
List
Item
List
text
List
Item
List
text
Item
Position
text
Code List
Position
CL Item
Sitting (1)
CL Item
Standing/upright (2)
CL Item
Sitting (3)
CL Item
Reclining (4)
CL Item
Lying (5)
Item
Presence
text
Code List
Presence
CL Item
Pulse presence (1)
CL Item
Heart beat presence (2)
CL Item
Present (3)
CL Item
Not detected (4)
Device
Item
Device
text
Exertion
Item
Exertion
text
Confounding factors
Item
Confounding factors
text
Item
Method
text
Code List
Method
CL Item
Palpation (1)
CL Item
Auscultation (2)
CL Item
Automatic, non-invasive (3)
CL Item
Automatic, invasive (4)
Clinical description
Item
Clinical description
text
Item
Clinical interpretation
text
Code List
Clinical interpretation
CL Item
Clinical interpretation (1)
CL Item
Rhythm (2)
Character
Item
Character
text
Maximum
Item
Maximum
text
Item
Body site
text
Code List
Body site
CL Item
Radial Artery - Left (1)
CL Item
Radial Artery - Right (2)
CL Item
Heart (3)
CL Item
Carotid Artery - Left (4)
CL Item
Carotid Artery - Right (5)
CL Item
Femoral Artery - Left (6)
CL Item
Femoral Artery - Right (7)
CL Item
Brachial artery - Right (8)
CL Item
Brachial artery - Left (9)
CL Item
Finger (10)
CL Item
Toe (11)
CL Item
Ear lobe (12)
Item
Irregular type
text
Code List
Irregular type
CL Item
Regularly Irregular (1)
CL Item
Irregularly Irregular (2)
Extension
Item
Extension
text
Comment
Item
Comment
text

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