- MetaDataSet:Sample Set : Template metadata sample set
- Symptome LEOSS
- Runny Nose
- Present
- Absent
- Unknown
- Sore throat
- Present
- Absent
- Unknown
- Dry cough
- Present
- Absent
- Unknown
- Productive cough
- Present
- Absent
- Unknown
- Wheezing
- Present
- Absent
- Unknown
- Dyspnoe
- Present
- Absent
- Unknown
- Feeling of breathlessness
- None
- Mild
- Moderate
- Severe
- Unknown
- Palpitations
- Present
- Absent
- Unknown
- Nausea / emesis
- Present
- Absent
- Unknown
- Diarrhea
- Present
- Absent
- Unknown
- Muscle aches
- Present
- Absent
- Unknown
- Muscle weakness
- Present
- Absent
- Unknown
- Fever
- Present
- Absent
- Unknown
- Delirium
- Present
- Absent
- Unknown
- Excessive tiredness
- Present
- Absent
- Unknown
- Headache
- Present
- Absent
- Unknown
- Meningism
- Present
- Absent
- Unknown
- Smell disorders
- Present
- Absent
- Unknown
- Taste disorder
- Present
- Absent
- Unknown
- Other neurological symptoms
- Present
- Absent
- Unknown
- Red eye
- Present
- Absent
- Unknown
- Asymptomatic
- Present
- Absent
- Unknown
- Cardiac arrhytmia
Symptom name should be coded with a terminology, where possible.
- Cardiac arrhytmia
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Life threatening arrhytmia
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Myocardial ischemia, acute coronary syndrome
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Myocarditis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- (Congestive) heart failure
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Pericardial effusion
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Any bleeding
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
- Respiratory Complications
Symptom name should be coded with a terminology, where possible.
- Need for oxygen supplementation
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Clinical indication for intubation
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Re-intubation
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- ECMO
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
- Renal complications
Symptom name should be coded with a terminology, where possible.
- Acute kidney injury (KDIGO)
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
- Stage I
- Stage II
- Stage III
- None
- Unknown
Symptom name should be coded with a terminology, where possible.
- New renal failure with need for dialysis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Not recovered kidney failure
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
- Thrombotic and thrombembolic complications
Symptom name should be coded with a terminology, where possible.
- Abdominal thrombosis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Arterial thrombosis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Microangiopathy, -thrombosis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Venous thrombosis, pulmonary thrombembolism
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
- Neurological complications
Symptom name should be coded with a terminology, where possible.
- Intracerebral bleeding
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Ischemic stroke
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Cause of stroke
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
- Cardioembolic
- Large-ateryatherosclerosis
- Small artery occlusion
- Other causes
- Undefined
Symptom name should be coded with a terminology, where possible.
- Stroke score NIHSS
>=0
Symptom name should be coded with a terminology, where possible.
- Meningitis/Encephalitis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Myositis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Seizure
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Neurological sequelae
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Severe cognitive impairment
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
- Further complications
Symptom name should be coded with a terminology, where possible.
- Vasculitis
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Septic shock
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- qSOFA >= 2
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
- Cardioembolic
- Large-ateryatherosclerosis
- Small artery occlusion
- Other causes
- Undefined
Symptom name should be coded with a terminology, where possible.
- Other complications, specify
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
>=0
Symptom name should be coded with a terminology, where possible.
- Severe fatigue
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Symptom name should be coded with a terminology, where possible.
- Other sequelae
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
0..1000 mmHg
0..1000 mmHg
- < 80mmHg
- 80-119 mmHg
- 120-139 mmHg
- 140-179 mmHg
- >= 180 mmHg
- not done
- unknown
- < 40 mmHg
- 41-60 mmHg
- 61-89 mmHg
- 90-110 mmHg
- > 110 mmHg
- not done
- unknown
0..1000 /min
- < 45 bpm
- 46-59 bpm
- 60-89 bpm
- 90-119 bpm
- >= 120 bpm
- not done
- unknown
SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.
- Percent
>=0 ml/dl
Coding with a terminology is preferred, if possible. For example, normal oxygen saturation or hypoxaemia.
- <60 %
- 60-69 %
- 70-79%
- 80-89%
- 90-95%
- 96-100%
- not done
- unknown
0..100; 30..200
Units:
- °C
- °F
- < 35.0°C
- 35.1 - 37.2°C
- 37.3 - 37.9°C
- 38.0 - 38.9°C
- 39.0 - 39.9°C
- >= 40°C
- not done
- unknown
Coded Text- Rectum
- Axilla
- Ear canal
- Forehead
- Mouth
- Nasopharynx
- Urinary bladder
- Intravascular
- Skin
- Vagina
- Oesophagus
- Inguinal skin crease
- Temple
Text
0..200 /min
For example: noting respiratory distress, use of accessory muscles or intermittent apnoea; noting characteristics such as stridor, sighing, grunting, groaning, gasping. Conducting a full respiratory examination, then some of these findings might be more appropriately recorded as part of examination findings.
- <= 16
- 16-21
- 22-29
- >=30
- not done
- unknown
A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.
The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.
Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
- PaO2
For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.
Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}]
- < 50 mmHg (<6.66)
- 50 - 59 mmHg (6.66 - 7.86)
- 60 - 69 mmHg (7.87 - 9.2)
- 70 - 79 mmHg (9.21 - 10.53)
- >= 80 mmHg (>10.53)
- not done
- unknown
The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.
Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
- PaCO2
For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.
Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}]
- < 30 mmHg (<4)
- 30 - 38 mmHg (4 - 5.06)
- 39 - 45 mmHg (5.07 - 5.99)
- 46 - 55 mmHg (6 - 7.33)
- > 55 mmHg (>7.33)
- not done
- unknown
More correctly known as the Modified Glasgow coma scale.
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
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
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
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
- 1: < 400
- 2: < 300
- 3: < 200 and artificial respiration
- 4: < 100 and artificial respiration
- 1: 13-14
- 2: 10-12
- 3: 6-9
- 4: <6
- 1: MAP < 70 mmHg
- 2: Dopamine ≤ 5 µg/kg/min or Dobutamine (regardless of dosage)
- 3: Dopamine > 5 µg/kg/min or adrenaline ≤ 0,1 µg/kg/min oder noradrenaline ≤ 0,1 µg/kg/min
- 4: Dopamine > 15 µg/kg/min oder adrenaline > 0,1 µg/kg/min or noradrenaline > 0,1 µg/kg/min
- 1: 1,2 -1,9 mg/dl
- 2: 2,0 - 5,9 mg/dl
- 3: 6,0 - 11,9 mg/dl
- 4: >12,0 mg/dl
- 1: < 150
- 2: < 100
- 3: < 50
- 4: < 20
- 1: 1,2 - 1,9 mg/dl
- 2: 2,0 - 3,4 mg/dl
- 3: 3,5 - 4,9 mg/dl
- 4: > 5 mg/dl
6..24
For example: screening for post-operative infection.
- Performed/carried out
- Not performed/carried out
Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.
This may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.
- Air trapping
- Areas of consolidation
- Bronchitits
- Crazy caving pattern
- Ground glass opacities
- Interlobular septal thickening
- Nodulary lesions
- Pleural effusion
- Normal CT
- Not done
For example: a note that the film was given to the patient.