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APGAR Score (EHR Archetype) - openEHR-EHR-OBSERVATION.apgar.v1

- 08.07.17 - 1 Formular, 1 Itemgruppe, 14 Datenelemente, 9 Sprachen
Itemgruppe: openEHR-EHR-OBSERVATION.apgar.v1
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.

Timed 25-Foot Walk (EHR Archetype) - openEHR-EHR-OBSERVATION.timed_25_foot_walk.v1

- 10.07.17 - 1 Formular, 1 Itemgruppe, 11 Datenelemente, 2 Sprachen
Itemgruppe: openEHR-EHR-OBSERVATION.timed_25_foot_walk.v1.xml
Derived from www.openehr.org . Use to record the measurements recorded during a Timed 25-Foot Walk test. This test is commonly carried out as one component of the Multiple Sclerosis Functional Composite (MSFC) assessment, but may be performed independently. The patient is directed to one end of a clearly marked 25-foot (7,62 m) course. Then he is instructed to walk this course as quickly as possible, but safely. The task is immediately administered again by having the patient walk back the same distance. Assistive devices (in general, customary walking devices) may be used when doing this task. Use the MSFC Manual for detailed administration instructions. The test should only be administred by a suitably trained person.

Paced Auditory Serial Addition Test (EHR Archetype) - openEHR-EHR-OBSERVATION.paced_auditory_serial_addition_test.v1

- 10.07.17 - 1 Formular, 1 Itemgruppe, 16 Datenelemente, 2 Sprachen
Itemgruppe: openEHR-EHR-OBSERVATION.paced_auditory_serial_addition_test.v1.xml
Derived from www.openehr.org . Use to record the measurements recorded during a Paced Auditory Serial Addition Test. This test is commonly carried out as one component of the Multiple Sclerosis Functional Composite, but may be performed independently. 61 single-digit numbers are presented to the subject one by one. During PASAT-3'' a new number is presented every three seconds, in the optional PASAT-2'' every two seconds. In each case the subject is asked to respond with the sum of the last two digits (not the running total). That is, there is a maximum of 60 possible correct sums. Use the MSFC Manual for detailed administration instructions. Prior to the recording of the actual tests at least one practice trial has to be performed (this training sequence is part of the PASAT). If less than three correct answers were given, the practice trial should be repeated (up to three times). If more than two correct answers were given, the PASAT-3'' can be administered (the patient should have understood the task sufficiently). To obtain additional information about the cognitive functions, the PASAT-2'' can be performed optionally after the 3'' test. The tests should only be administered by a suitably trained person.

Nine Hole Peg Test (EHR Archetype) - openEHR-EHR-OBSERVATION.nine_hole_peg_test.v1

- 10.07.17 - 1 Formular, 1 Itemgruppe, 18 Datenelemente, 3 Sprachen
Itemgruppe: openEHR-EHR-OBSERVATION.nine_hole_peg_test.v1.xml
Derived from www.openehr.org . Use to record the measurements recorded during a Nine Hole Peg Test. This test is commonly carried out as one component of the Multiple Sclerosis Functional Composite (MSFC) assessment, but may be performed independently. Both the dominant and non-dominant hand of the patient are tested twice (two consecutive trials of the dominant hand, followed by two consecutive trials of the non-dominant hand). For each trial nine pegs are picked one by one from a container, placed in the holes on a pegboard and then separately returned to the container. The subject may only use one hand at each trial, but may hold the pegboard with the free hand. This archetype covers variations of the test. According to Mathiowetz et al. (1985) an untimed practice trial should be administered prior to the timed trial for each hand. The MSFC Manual stipulates two timed trials for each hand, but no practice trial. Use the MSFC Manual or see Mathiowetz et al. (1985) for detailed administration instructions. The test should only be administered by a suitably trained person.

MSFC Score (EHR Archetype) - openEHR-EHR-OBSERVATION.msfc_score.v1

- 09.07.17 - 1 Formular, 1 Itemgruppe, 5 Datenelemente, 2 Sprachen
Itemgruppe: openEHR-EHR-OBSERVATION.msfc_score.v1.xml
Derived from www.openehr.org . Use to record the MSFC Score and the reference data set, as well as links to the measured results of the three individual tests (Timed 25-Foot Walk, Nine Hole Peg Test and Paced Auditory Serial Addition Test). The MSFC Score is a computed value based on the average of each test result, adjusted to the reference population. I.e. MSFC Score = 1/3 * (Z_arm,avg. + Z_leg,avg. + Z_cognitive), where Z_x = Z-score of each test result. This score has to be computed externally, only the resulting value is to be recorded here. Use the MSFC Manual for further scoring instructions, formulas and background information.

NEWS UK RCP (EHR Archetype) - openEHR-EHR-OBSERVATION.news_uk_rcp.v1

- 09.07.17 - 1 Formular, 1 Itemgruppe, 10 Datenelemente, 4 Sprachen
Itemgruppe: openEHR-EHR-OBSERVATION.news_uk_rcp.v1.xml
Derived from www.openehr.org . Use to record a composite score to support assessment of the degree of clinical deterioration in an unwell patient, over the age of 16 years.

Children's Global Assessment Scale (EHR Archetype) - openEHR-EHR-OBSERVATION.cgas.v1

- 09.07.17 - 1 Formular, 1 Itemgruppe, 5 Datenelemente, 2 Sprachen
Itemgruppe: openEHR-EHR-OBSERVATION.cgas.v1.xml
Derived from www.openehr.org . Use to score a child's most impaired level of emotional and behavioural functioning in the specified time period by selecting the lowest level which describes his/her functioning on a hypothetical continuum of health-illness. The scores can range from 1, which is the very worst, to 100, which is the very best. Use intermediary levels (e.g. 35, 58, 62). The score is used for children over the age of 4. Different sources have different upper limits for the age of the individual being scored, the most common being 16 or 18 years of age.

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