| ARCHETYPE ID | openEHR-EHR-OBSERVATION.refraction.v0 |
|---|---|
| Concept | Refraction assessment |
| Description | Assessment of the refraction required to achieve optimal visual acuity. |
| Use | Use to record the results of measurement of refraction. The 'Description' data element can be used to record simple narrative summary or as a means to integrate legacy data. |
| Purpose | For recording the results of a refraction assessment, either performed on the patient's usual correction or by refraction of the patient. |
| References | Visual Acuity [Internet]. Wikipedia. Available from: http://en.wikipedia.org/wiki/Visual_acuity Aylward W [Internet].Coding Visual Acuity, openEyes Project;2012.Available from http://www.openeyes.org.uk/documents/OpenEyes%20Coding%20Visual%20Acuity.pdf IHE Eye Care Domain. General Eye Evaluation (GEE) [Internet]. IHE; 2012. Available from: http://www.ihe.net/Technical_Framework/upload/IHE_EyeCare_Supp_GEE_Rev1-1_TI_2012-06-29.pdf Royal College of Opthalmologists. Cataract National Dataset for Adults [Internet]. 2011. Available from: http://www.rcophth.ac.uk/page.asp?section=583§ionTitle=Cataract+National+Data+Set+for+Adults CfH, UK. Do Once & Share - Glaucoma [Internet]. [cited 2012 Sep 26]. Available from: http://www.doasglaucoma.org/ DICOM Supplement 30 [Internet]. [cited 2012 Sep 26]. Available from: http://medical.nema.org/ Practical Ophthalmology: A Manual for Beginning Residents, 6th Edition [Paperback] American Academy Of Ophthalmology (Author), Fred M. Wilson II (Editor), MD (Editor) |
| Copyright | © openEHR Foundation |
| Authors | Author name: Ian McNicoll Organisation: Ocean Informatics, UK Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 2012-07-18 |
| Other Details Language | Author name: Ian McNicoll Organisation: Ocean Informatics, UK Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 2012-07-18 |
| Other Details (Language Independent) |
|
| Keywords | eye, sight, vision, ophthalmic, visual, refraction, refraction, correction |
| Lifecycle | in_development |
| UID | 098f8a46-e359-4a1d-9fec-5a5afce6dd81 |
| Language used | en |
| Citeable Identifier | 1246.145.2777 |
| Revision Number | 0.0.1-alpha |
| protocol | |
| Device Details | Device Details: Details of the device used to measure refraction. Include: openEHR-EHR-CLUSTER.device.v1 and specialisations |
| Extension | Extension: Additional information required to capture local content or to align with other reference models/formalisms. For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents. Include: All not explicitly excluded archetypes |
| state | |
| Confounding Factors | Confounding Factors: Patient circumstances which affect interpretation of the result. Often termed 'reliability' in opthalmological documentation. Examples: 'Patient was confused', 'Low light conditions'. |
| Refractive Correction | Refractive Correction: The specific type(s) of refractive correction applied. Examples: 'No correction : unaided', 'Pinhole'.
|
| data | |
| Description | Description: An overall narrative description of the visual acuity test result. |
| Result details | Result details: Details of the refraction result for each eye. |
| Test eye | Test eye: Identification of the eye which is being tested.
|
| Refraction details | Refraction details: Details of refraction for a single eye. Include: openEHR-EHR-CLUSTER.refraction_ |
| No test result | No test result: No refraction test result is available for the test eye. Record as True if the clinician was unable to record a result for the test eye. Allowed values: {true} |
| Reason for no test result | Reason for no test result: Reason why no refraction result is available for the test eye. For example, patient was not cooperative; patient was not capable; ran out of time. |
| Interpretation | Interpretation: The test result expressed as a qualitative term, normally coded. Example: "Visual Acuity 20/20" or "Jaeger 'J2' score". |
| Overall interpretation | Overall interpretation: A term, commonly coded, expressing an overall interpretation of the visual acuity test. |
| Comment | Comment: Any additional narrative comment about the visual acuity test. |
| Examination not done | Examination not done: Details to explicitly record that this test was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| events | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Other contributors | Gustavo M Bacelar-Silva, Brazil |
| Translators |