| ARCHETYPE ID | openEHR-EHR-OBSERVATION.fundoscopic_examination.v0 |
|---|---|
| Concept | Fundoscopic examination of eyes |
| Description | Record of clinical findings on fundoscopy of eyes. |
| Purpose | To record details about clinical findings on fundoscopy of eyes. |
| References | Lamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study. Ophthalmology. 2012 Mar;119(3):617-24. doi: 10.1016/j.ophtha.2011.09.013. Epub 2012 Jan 3. PubMed PMID: 22218140; PubMed Central PMCID: PMC3294008. Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991 May;98(5 Suppl):786-806. PubMed PMID: 2062513. Li HK, Horton M, Bursell SE, Cavallerano J, Zimmer-Galler I, Tennant M, Abramoff M, Chaum E, Debuc DC, Leonard-Martin T, Winchester M; American Telemedicine Association Diabetic Retinopathy Telehealth Practice Recommendations Working Group., Lawrence MG, Bauman W, Gardner WK, Hildebran L, Federman J. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health. 2011 Dec;17(10):814-37. doi: 10.1089/tmj.2011.0075. Epub 2011 Oct 4. Review. PubMed PMID: 21970573. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2008-07-27 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2008-07-27 |
| Other Details (Language Independent) |
|
| Keywords | |
| Lifecycle | in_development |
| UID | d8e13c17-6da2-40b7-b945-5f93df77daa4 |
| Language used | en |
| Citeable Identifier | 1246.145.2816 |
| Revision Number | 0.0.1-alpha |
| protocol | |
| Method | Method: Method chosen to perform the funduscopic examination.
|
| Device details | Device details: Details of the device used to acquire eye fundus images. Include: openEHR-EHR-CLUSTER.device.v1 and specialisations |
| Field angle | Field angle: Describes the optical acceptance angle of the lens used during the test.
|
| Attempts | Attempts: Number of attempts before obtaining the acquisition (doesn't compute if test is repeated by a specific recognized technical failure). min: >=1; max: <=3 |
| (Subdivision of the retina) | (Subdivision of the retina): Subdivision of the retina identifying eye fundus image locations. Runtime name constraint: Subdivision of retina [*] |
| (ETRDS fields) | (ETRDS fields): Subdivision of the retina based on Diabetic Retinopathy Study fields.
Runtime name constraint: Diabetic Retinopathy Study field [*] |
| Mosaic and peripherals | Mosaic and peripherals: Division of the retina in quadrants + mosaic obtained from the combination of them.
|
| Shadow artifact | Shadow artifact: True if shadow artifact is present on the border of the image. |
| Cataract artifact | Cataract artifact: True if cataract obstructs the visualization of eye fundus. |
| Quality of visualisation | Quality of visualisation: Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus. 1: Quality inadequate for any diagnostic purpose [*] 2: Unable to exclude all emergent findings [*] 3: Only able to exclude emergent findings [*] 4: Quality not ideal, but is possible to exclude subtle findings [*] 5: Ideal quality [*] |
| Visualisation description | Visualisation description: Narrative description about visualisation. |
| High refraction | High refraction: True if the refraction of the eye exceeds the range from -12D to +15D. |
| 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: Narrative description of factors, not recorded elsewhere, that may influence the clinical findings. |
| Mydriatic used | Mydriatic used: True if mydriatic is used. |
| Small pupil | Small pupil: True if during the acquisition, pupil diameter is smaller than normal (3,3mm). |
| Uncooperative patient | Uncooperative patient: True if patient doesn't collaborate during the image acquisition. |
| data | |
| Test Result | Test Result: Details of the funduscopic examination test result for each eye. |
| Eye examined | Eye examined: Identification of the eye which is being examined. Matches to DICOM Laterality (0020,0060) attribute.
|
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination of the eye examined. |
| Red reflex | Red reflex: True if Red Reflex is present. |
| Optic disc description | Optic disc description: Narrative description about the optic disc. |
| Macula description | Macula description: Narrative description about the macula. |
| Retinal arteries description | Retinal arteries description: Narrative description about the retinal arteries. |
| Retinal veins description | Retinal veins description: Narrative description about the retinal veins. |
| Retinal background description | Retinal background description: Narrative description about the retinal background. |
| Vitreous description | Vitreous description: Narrative description about the vitreous humour. |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings for the eye examined. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Include: openEHR-EHR-CLUSTER.multimedia.v0 and specialisations |
| Additional findings | Additional findings: Additional structured details about the physical examination findings. Include: openEHR-EHR-CLUSTER.clinical_ |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| 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 | Aitor Eguzkitza, Universidad Pública de Navarra - Complejo Hospitalario de Navarra, aitor.eguzkiza@unavarra.es Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es José Andonegui, Hospital de Navarra, jose.andonegui.navarro@cfnavarra.es Heather Leslie, Atomica Informatics, Australia |
| Translators |
|