ID

29634

Beschreibung

http://openehr.org/ckm/ Use to record the results of measurement of visual acuity, for both near and distance testing. The 'Clinical Description' data element can be used to record simple narrative summary or as a means to integrate legacy data. Detailed, structured visual acuity results are preferred and are generally recorded for each eye in turn. Visual acuity may be recorded using a number of different notation formats e.g. Snellen, logMar, EDTRS etc. In some settings the visual acuity result, originally captured using one of the standard notations, is converted to a 'Derived Score' capable of algorithmic conversion to the other notations., with details of the original notation and algorithm employed recorded as part of protocol. Where visual acuity is recorded using coded terms such as 'Visual Acuity 6/6' or 'Jaeger score N1', the 'Clinical Interpretation' element should be used, allowing the result to be captured for each eye. 'Overall Interpretation' should be used where the interpretation applies to both eyes or the test result as a whole. The 'Absent Test Result' element may be used to record circumstances where a test could not be performed or completed. Further details may be recorded under 'Confounding Factors' or 'Additional Comment'. When performing visual acuity testing it is customary to record a series of tests sharing a common charting methodology but with different phases of corrective refraction e.g. Unaided, Usual correction, Best corrected visual acuity etc. Each of these phases should be recorded using a separate Entry record, with the name of the test phase carried in 'Test Name'. Further specific details of the exact correction applied (which may involve applying multiple refractions) may be captured in 'Refractive Correction' and 'Refraction Details' the latter making use of separate Cluster archetypes, one for each eye.

Link

http://openehr.org/ckm/

Stichworte

Versionen (1)
  1. 10.04.18 10.04.18 - Halim Ugurlu
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openEHR Foundation

Hochgeladen am

10. April 2018

DOI

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Lizenz

Creative Commons BY-NC 3.0
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openEHR-EHR-OBSERVATION.visual_acuity.v0

Englisch

openEHR-EHR-OBSERVATION.visual_acuity.v0

1 Formulare  
  1. StudyEvent: openEHR-EHR-OBSERVATION.visual_acuity.v0
    1. openEHR-EHR-OBSERVATION.visual_acuity.v0
openEHR-EHR-OBSERVATION.visual_acuity.v0.xml
Beschreibung

openEHR-EHR-OBSERVATION.visual_acuity.v0.xml

Alias
UMLS CUI-1
C0042812
Visual acuity test result
Beschreibung

Visual acuity is a measure of the spatial resolution of the visual processing system.

Datentyp

text

Alias
UMLS CUI [1,1]
C0042812
UMLS CUI [1,2]
C0242485
Eye examined
Beschreibung

The eye which is being examined.

Datentyp

text

Alias
UMLS CUI [1,1]
C0015392
UMLS CUI [1,2]
C0332128
Derived Score
Beschreibung

Visual acuity expressed as an integer score which is calculated from one or more of the other result notation formats. The original notation should be captured using 'Derived Score Original Notation' format'.

Datentyp

integer

Alias
UMLS CUI [1,1]
C0042812
UMLS CUI [1,2]
C0449820
Chart Optotype
Beschreibung

The style of chart optotype used to assess visual acuity.

Datentyp

text

Alias
UMLS CUI [1]
C0179887
Chart Scoring Algorithm
Beschreibung

The algorithm used to determine the score.

Datentyp

text

Alias
UMLS CUI [1]
C0036449
Chart Method
Beschreibung

The charting method used to measure visual acuity.

Datentyp

text

Alias
UMLS CUI [1]
C3704133
Measurement Device Details
Beschreibung

Details of the device used to measure visual acuity.

Datentyp

text

Alias
UMLS CUI [1,1]
C2825498
UMLS CUI [1,2]
C0042812
Notation
Beschreibung

Details of a visual acuity result recorded using one of the result notation formats.

Datentyp

text

Alias
UMLS CUI [1,1]
C0042812
UMLS CUI [1,2]
C1274040
UMLS CUI [1,3]
C0868996
Description
Beschreibung

An overall narrative description of the visual acuity test result.

Datentyp

text

Alias
UMLS CUI [1,1]
C0042812
UMLS CUI [1,2]
C1274040
UMLS CUI [1,3]
C0678257
Comment
Beschreibung

Any additional narrative comment about the visual acuity test.

Datentyp

text

Alias
UMLS CUI [1,1]
C0947611
UMLS CUI [1,2]
C0042812
UMLS CUI [1,3]
C1274040
Refractive Correction
Beschreibung

The specific type(s) of refractive correction applied when measuring visual acuity.

Datentyp

text

Alias
UMLS CUI [1,1]
C0034951
UMLS CUI [1,2]
C1947976
UMLS CUI [1,3]
C0185125
Result details
Beschreibung

Details of the visual field test result for each eye.

Datentyp

text

Alias
UMLS CUI [1,1]
C1522508
UMLS CUI [1,2]
C0042826
UMLS CUI [1,3]
C0392366
Overall Interpretation
Beschreibung

A term, commonly coded, expressing an overall interpretation of the visual acuity test.

Datentyp

text

Alias
UMLS CUI [1,1]
C0420833
UMLS CUI [1,2]
C0042812
No test result
Beschreibung

No visual acuity test result is available for the test eye.

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0587081
UMLS CUI [1,2]
C1518422
Letter Termination Adjustment
Beschreibung

A line termination adjustment score applied to the visual acuity result.

Datentyp

integer

Alias
UMLS CUI [1,1]
C0456081
UMLS CUI [1,2]
C0449820
UMLS CUI [1,3]
C0042812
Interpretation
Beschreibung

Clinical interpretation of all results for the test eye.

Datentyp

text

Alias
UMLS CUI [1,1]
C4086187
UMLS CUI [1,2]
C0015392
Refraction Details
Beschreibung

Details of the refraction applied to each eye.

Datentyp

text

Alias
UMLS CUI [1]
C0429585
Testing Distance
Beschreibung

The distance at which the subject's visual acuity was measured.

Datentyp

float

Alias
UMLS CUI [1]
C0429925
Derived Score Original Notation
Beschreibung

The original visual acuity result notation from which the Derived Score was calculated.

Datentyp

text

Alias
UMLS CUI [1,1]
C2347411
UMLS CUI [1,2]
C0200150
UMLS CUI [1,3]
C0868996
Confounding Factors
Beschreibung

Patient circumstances which affect interpretation of the result. Often termed 'reliability' in opthalmological documentation.

Datentyp

text

Alias
UMLS CUI [1,1]
C0009673
UMLS CUI [1,2]
C3845861
Derived Score Algorithm
Beschreibung

Details of the algorithm used to calculate a derived score.

Datentyp

text

Alias
UMLS CUI [1,1]
C0002045
UMLS CUI [1,2]
C1522508
Pupillary State
Beschreibung

Details of the state of the pupil on examination.

Datentyp

text

Alias
UMLS CUI [1,1]
C0034121
UMLS CUI [1,2]
C1442792
Any event
Beschreibung

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

Datentyp

text

Alias
UMLS CUI [1]
C0441471
Test name
Beschreibung

The name of the exact visual acuity test performed. This generally represents a broad category of applied refraction. Specific refraction details can be described using 'Refractive Correction'.

Datentyp

text

Alias
UMLS CUI [1,1]
C0200150
UMLS CUI [1,2]
C0027365
Reason for no test result
Beschreibung

Reason why no visual acuity test result is available for the test eye.

Datentyp

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C3841220
Test not done
Beschreibung

Details to explicitly record that this test was not performed.

Datentyp

text

Alias
UMLS CUI [1,1]
C0042793
UMLS CUI [1,2]
C3841220
UMLS CUI [1,3]
C1522508
Extension
Beschreibung

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

Datentyp

text

Alias
UMLS CUI [1]
C1546922
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Ähnliche Modelle

openEHR-EHR-OBSERVATION.visual_acuity.v0

1 Formulare
  1. StudyEvent: openEHR-EHR-OBSERVATION.visual_acuity.v0
    1. openEHR-EHR-OBSERVATION.visual_acuity.v0
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
openEHR-EHR-OBSERVATION.visual_acuity.v0.xml
C0042812 (UMLS CUI-1)
Visual acuity test result
Item
Visual acuity test result
text
C0042812 (UMLS CUI [1,1])
C0242485 (UMLS CUI [1,2])
Item
Eye examined
text
C0015392 (UMLS CUI [1,1])
C0332128 (UMLS CUI [1,2])
Eye examined
Code List
Eye examined
CL Item
Left eye (1)
CL Item
Right eye (2)
CL Item
Both eyes simultaneously (3)
Derived Score
Item
Derived Score
integer
C0042812 (UMLS CUI [1,1])
C0449820 (UMLS CUI [1,2])
Item
Chart Optotype
text
C0179887 (UMLS CUI [1])
Chart Optotype
Code List
Chart Optotype
CL Item
Letter (1)
CL Item
Orientation (2)
CL Item
Picture (3)
Item
Chart Scoring Algorithm
text
C0036449 (UMLS CUI [1])
Chart Scoring Algorithm
Code List
Chart Scoring Algorithm
CL Item
Single letter (1)
CL Item
Whole line (2)
CL Item
Last line single letter (3)
Item
Chart Method
text
C3704133 (UMLS CUI [1])
Chart Method
Code List
Chart Method
CL Item
logMar chart (1)
CL Item
Snellen chart (2)
CL Item
ETDRS chart (3)
CL Item
Picture chart (4)
CL Item
Reduced logMar (5)
CL Item
Reduced Snellen (6)
CL Item
Faculty of Ophthalmologists 'N' Score (7)
CL Item
Jaeger 'J' Score (8)
Measurement Device Details
Item
Measurement Device Details
text
C2825498 (UMLS CUI [1,1])
C0042812 (UMLS CUI [1,2])
Notation
Item
Notation
text
C0042812 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
C0868996 (UMLS CUI [1,3])
Description
Item
Description
text
C0042812 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
C0678257 (UMLS CUI [1,3])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1,1])
C0042812 (UMLS CUI [1,2])
C1274040 (UMLS CUI [1,3])
Item
Refractive Correction
text
C0034951 (UMLS CUI [1,1])
C1947976 (UMLS CUI [1,2])
C0185125 (UMLS CUI [1,3])
Refractive Correction
Code List
Refractive Correction
CL Item
Spectacles (1)
CL Item
Contact lenses (2)
CL Item
Pinhole (3)
CL Item
Autorefraction (4)
CL Item
Retinoscopy (5)
Result details
Item
Result details
text
C1522508 (UMLS CUI [1,1])
C0042826 (UMLS CUI [1,2])
C0392366 (UMLS CUI [1,3])
Overall Interpretation
Item
Overall Interpretation
text
C0420833 (UMLS CUI [1,1])
C0042812 (UMLS CUI [1,2])
No test result
Item
No test result
boolean
C0587081 (UMLS CUI [1,1])
C1518422 (UMLS CUI [1,2])
Letter Termination Adjustment
Item
Letter Termination Adjustment
integer
C0456081 (UMLS CUI [1,1])
C0449820 (UMLS CUI [1,2])
C0042812 (UMLS CUI [1,3])
Interpretation
Item
Interpretation
text
C4086187 (UMLS CUI [1,1])
C0015392 (UMLS CUI [1,2])
Refraction Details
Item
Refraction Details
text
C0429585 (UMLS CUI [1])
Testing Distance
Item
Testing Distance
float
C0429925 (UMLS CUI [1])
Item
Derived Score Original Notation
text
C2347411 (UMLS CUI [1,1])
C0200150 (UMLS CUI [1,2])
C0868996 (UMLS CUI [1,3])
Derived Score Original Notation
Code List
Derived Score Original Notation
CL Item
US Snellen (1)
CL Item
Metric Snellen (2)
CL Item
Decimal Snellen (3)
CL Item
ETDRS Letters (4)
CL Item
Low Vision Score (5)
CL Item
logMar (6)
Confounding Factors
Item
Confounding Factors
text
C0009673 (UMLS CUI [1,1])
C3845861 (UMLS CUI [1,2])
Derived Score Algorithm
Item
Derived Score Algorithm
text
C0002045 (UMLS CUI [1,1])
C1522508 (UMLS CUI [1,2])
Pupillary State
Item
Pupillary State
text
C0034121 (UMLS CUI [1,1])
C1442792 (UMLS CUI [1,2])
Any event
Item
Any event
text
C0441471 (UMLS CUI [1])
Item
Test name
text
C0200150 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
Test name
Code List
Test name
CL Item
Pinhole visual acuity (1)
CL Item
Usual corrected visual acuity (2)
CL Item
Best corrected visual acuity (3)
CL Item
Unaided visual acuity (4)
Reason for no test result
Item
Reason for no test result
text
C0566251 (UMLS CUI [1,1])
C3841220 (UMLS CUI [1,2])
Test not done
Item
Test not done
text
C0042793 (UMLS CUI [1,1])
C3841220 (UMLS CUI [1,2])
C1522508 (UMLS CUI [1,3])
Extension
Item
Extension
text
C1546922 (UMLS CUI [1])
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