TEMPLATE Vitalparameter (Vitalparameter)

TEMPLATE ID	Vitalparameter
Concept	Vitalparameter
Description	Not Specified
Purpose	Not Specified
References
Authors	date: 2023-12-13; name: test
Other Details Language	date: 2023-12-13; name: test
Other Details (Language Independent)	Sem Ver: 15.0.0 MD5-CAM-1.0.1: 244fe62a4bb111c48458c07727f739fe PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.3857
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Vitalparameter	Vitalparameter: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Report ID	Report ID: Identification information about the report.
Status	Status: The status of the entire report. Note: This is not the status of any of the report components.
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Körpergröße	Körpergröße: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
state
Data
Größe	Größe: The length of the body from crown of head to sole of foot. 0..1000 cm Annotations LOINC: 8302-2
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
Body weight	Body weight: Measurement of the body weight of an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Weight	Weight: The weight of the individual. 0..1000 kg Annotations LOINC: 29463-7
Comment	Comment: Additional narrative about the measurement of Body weight, not captured in other fields.
Body mass index	Body mass index: Calculated measurement which compares a person's weight and height. Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Body mass index	Body mass index: Index describing ratio of weight to height. 0..1000 kg/m² (UCUM: kg/m2) Annotations LOINC: 39156-5
Comment	Comment: Additional narrative about the calculation, not captured in other fields.
Body temperature	Body temperature: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Temperature	Temperature: The measured temperature. 0..100; 30..200 Units: °C (UCUM: Cel) °F (UCUM: [degF]) Annotations LOINC: 8310-5
Comment	Comment: Additional comment about the body temperature measurement not captured in other fields.
Protocol
Location of measurement	Location of measurement: Simple description about the site of measurement. Coded Text Rectum Axilla Ear canal Forehead Mouth Nasopharynx Urinary bladder Intravascular Skin Vagina Oesophagus Inguinal skin crease Temple Text
Blood pressure	Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
Data	Data: History Structural node.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Systolic	Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Mean arterial pressure	Mean arterial pressure: The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle. 0..1000 mmHg (UCUM: mm[Hg])
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
Protocol	Protocol: List structure.
Location of measurement	Location of measurement: Simple body site where blood pressure was measured.
Method	Method: Method of measurement of blood pressure. Auscultation Palpation Machine Invasive
Blutdruck invasiv	Blutdruck invasiv: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
Data	Data: History Structural node.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Systolic	Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Mean arterial pressure	Mean arterial pressure: The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle. 0..1000 mmHg (UCUM: mm[Hg])
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
Protocol	Protocol: List structure.
Location of measurement	Location of measurement: Simple body site where blood pressure was measured.
Method	Method: Method of measurement of blood pressure. Invasive
Puls	Puls: The rate and associated attributes for a pulse or heart beat.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Rate	Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min Annotations LOINC: 8889-8
Regularity	Regularity: Regularity of the pulse or heart beat. Regular Irregular
Comment	Comment: Additional narrative about the pulse or heart beat findings not captured in other fields.
Protocol
Body site	Body site: Body site where the pulse or heart beat were observed.
ECG result	ECG result: Measurement of the electrical activity generated by the heart. Also known as an electrocardiograph or EKG.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Ventricular heart rate	Ventricular heart rate: The frequency of ventricular electrical contractions across the ECG as a whole (multiple leads). Also known as the RR rate, QRS rate or electrical heart rate. The ventricular heart rate is measured from R wave to R wave and calculated across the ECG as a whole (multiple leads). >=0 /min Annotations LOINC: 8867-4
Sauerstoffsättigung	Sauerstoffsättigung: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
SpO2	SpO2: The saturation of oxygen in the peripheral blood, measured via pulse oximetry. SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood. Percent Annotations LOINC: 20564-1
type
Comment	Comment: A text comment about the pulse oximetry result.
State
Inspired oxygen	Inspired oxygen: The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate.
O2-Flussrate	O2-Flussrate: Oxygen flow rate given to an individual. For example '5 l/min'. 0..50000; 0..50 Units: ml/min l/min Annotations LOINC: 3151-8
FiO2	FiO2: Fraction of oxygen in inspired air. For example: '0.28'. Unitary Annotations LOINC: 71835-3
Method of oxygen delivery	Method of oxygen delivery: The method used to deliver the oxygen. Intended to capture only simple description / terms, for example: 'nasal prongs'. The 'Oxygen delivery detail' slot may be used for more detailed or complex recording. High-Flow Blender-Fluss [...]
Respiration	Respiration: The characteristics of spontaneous breathing by an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Rate	Rate: The frequency of spontaneous breathing. 0..200 /min Annotations LOINC: 9279-1
Comment	Comment: Additional narrative about the respirations, not captured in other fields.
Pain scale (VAS)	Pain scale (VAS): The pain scale VAS is a visual analog scale for the subjective measurement of the sensation intensity of pain.
Data
Any event	Any event: A defined point in time that can be explicitly defined in the template or at application runtime.
Data
Overall score	Overall score: Pain intensity from 0 (no pain) to 10 (most severe, unbearable pain). 0..10
Comment	Comment: Additional information that is not adequately captured by the visual scale but may be helpful in assessing pain.
State
Influential factors	Influential factors: Any incidental factors related to the patient's condition that could affect the clinical interpretation of the measurement. in Ruhe in Belastung
Glasgow Coma Scale (GCS)	Glasgow Coma Scale (GCS): Fifteen point scale used to assess impairment of consciousness in response to defined stimuli. More correctly known as the Modified Glasgow coma scale.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Best eye response (E)	Best eye response (E): Best response of eyes to test stimulus. Most commonly, the score for eye response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot physically open their eyes due to other injuries, then the "Not Applicable" null flavour should be recorded. 1: None 2: To pressure 3: To sound 4: Spontaneous
Best verbal response (V)	Best verbal response (V): Best verbal response to test stimulus. Most commonly, the score for verbal response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care is intubated, then the "Not Applicable" null flavour should be recorded. 1: None 2: Sounds 3: Words 4: Confused 5: Orientated
Best motor response (M)	Best motor response (M): Best motor response to test stimulus. Most commonly, the score for motor response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot move their limbs due to injury or paralysis, then the "Not Applicable" null flavour should be recorded. 1: None 2: Extension 3: Abnormal flexion 4: Normal flexion 5: Localising 6: Obeys commands
Total score	Total score: The sum of the ordinal scores recorded for each of the three component responses. The Total Score may be derived as the sum of the three response data elements and, if so, should be validated by the clinical information system against the individual scores entered by the clinician to ensure there is no conflict or inconsistency. Do not report a total score when one or more components are not testable because the score will be artificially low - in this situation record the EVM profile. 3..15
Comment	Comment: Additional narrative about the measurement of the scale not captured in other fields. Record the reasons for inability to test in the 'Confounding factors' data element.

TEMPLATE Vitalparameter (Vitalparameter)

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