ISO_639-1
en
2025-04-11
in_development
1.0.0
da48e1abb8a2ebc64b5e47923e561015
E51B66549F2C04336B514E1DAE9B93C8
Archetype Designer v1.24.16, user=151435822@github, repositoryId=openehr--e7s
ISO_639-1
en
Not Specified
1dc34da9-704e-4464-8196-5ab1c933e100
vital_signs_basic.v1
vital_signs_basic.v1
COMPOSITION
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at0000
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DV_CODED_TEXT
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false
1
1
defining_code
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true
false
false
1
1
false
CODE_PHRASE
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true
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false
1
1
openehr
433
context
true
true
false
false
0
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false
EVENT_CONTEXT
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true
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false
1
1
other_context
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ITEM_TREE
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at0001
items
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CLUSTER
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true
0
at0002
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
content
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0
1
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OBSERVATION
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HISTORY
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EVENT
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data
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ITEM_TREE
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items
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ELEMENT
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DV_QUANTITY
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openehr
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false
0.0
1000.0
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0
0
/min
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state
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ITEM_TREE
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at0012
items
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1
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CLUSTER
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at1017
archetype_id/value matches {/openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0010
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at1013
archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at1056
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.pulse.v2
Pulse/Heart beat
The rate and associated attributes for a pulse or heart beat.
structure
@ internal @
history
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Rate
The rate of the pulse or heart beat, measured in beats per minute.
Regularity
Regularity of the pulse or heart beat.
Regular
The pattern is regular.
Regularly Irregular
The pattern is irregular in a regular pattern,. For example, a dropped beat once every 'n' beats.
Irregularly Irregular
The pattern is irregular in a chaotic and unpredictable manner. For example, atrial fibrillation.
List
@ internal @
List
@ internal @
Position
The body position of the subject during the observation.
Lying
The subject was lying flat.
Sitting
The subject was sitting (for example on bed or chair).
Reclining
The subject was reclining at an approximate angle of 45 degrees, with the legs elevated to the level of the pelvis.
Standing/upright
The subject was standing, walking or running.
Presence
Presence of a pulse or heart beat.
Device
Details about the device used to measure the pulse rate or heart rate.
Exertion
Details about physical exertion being undertaken during the examination.
Confounding factors
Narrative description about any incidental factors that may affect interpretation of the physical findings.
Method
Method used to observe the pulse or heart beat.
Clinical description
Narrative description about the pulse or heart beat.
Clinical interpretation
Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm.
Present
A pulse or heart beat can be detected.
Not detected
A pulse or heart beat cannot be detected.
Irregular
The pattern is irregular.
Character
Description of the character of the pulse or heart beat.
Palpation
The findings are observed by physical touch of the observer on the subject.
Auscultation
The findings are observed with the assistance of a device, such as a stethoscope.
Automatic, non-invasive
The findings are observed non-invasively using a device such as a pulse oximeter or a stethoscope.
Maximum
Maximum pulse rate or heart rate observed during a period of exertion.
Body site
Body site where the pulse or heart beat were observed.
Radial Artery - Left
The left radial artery.
Radial Artery - Right
The right radial artery.
Heart
The region of the heart.
Carotid Artery - Left
The left carotid artery.
Carotid Artery - Right
The right carotid artery.
Femoral Artery - Left
The left femoral artery.
Femoral Artery - Right
The right femoral artery.
Finger
An unspecified finger.
Brachial artery - Left
The left brachial artery.
Brachial artery - Right
The right brachial artery.
Automatic, invasive
The findings are observed invasively using a device such as an arterial catheter.
Ear lobe
The lobe of an unspecified ear.
Toe
An unspecified toe.
Irregular type
More specific pattern of an irregular pulse or heart beat.
Extension
Additional information required to capture local content or to align with other reference models/formalisms.
Clinical interpretation
Generic label to allow for any or all statements about the pulse or heart beat.
Rhythm
Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination.
Comment
Additional narrative about the pulse or heart beat findings not captured in other fields.
OBSERVATION
true
true
false
false
0
1
at0000
data
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1
1
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HISTORY
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1
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at0001
events
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EVENT
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at0006
data
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false
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ITEM_TREE
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at0003
items
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ELEMENT
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1
at0004
value
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0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
125
true
false
false
false
0.0
1000.0
true
true
false
false
0
0
mm[Hg]
ELEMENT
true
true
false
false
0
1
at0005
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
125
true
false
false
false
0.0
1000.0
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true
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0
0
mm[Hg]
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true
false
false
true
0
state
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false
0
1
false
ITEM_TREE
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false
1
1
at0007
items
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false
0
1
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CLUSTER
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true
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false
0
1
at1030
archetype_id/value matches {/openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0011
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at1057
archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at1025
archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at1058
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.blood_pressure.v2
Blood pressure
The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation.
History
History Structural node.
blood pressure
@ internal @
Systolic
Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle.
Diastolic
Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle.
Any event
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
state structure
@ internal @
Position
The position of the individual at the time of measurement.
Tree
List structure.
Cuff size
The size of the cuff used for blood pressure measurement.
Location of measurement
Simple body site where blood pressure was measured.
Adult Thigh
A cuff used for an adult thigh.
Large Adult
A cuff for adults with larger arms.
Adult
A cuff that is standard for an adult.
Right arm
The right arm of the person.
Left arm
The left arm of the person.
Right thigh
The right thigh of the person.
Left thigh
The left thigh of the person.
Comment
Additional narrative about the measurement, not captured in other fields.
Standing
Standing at the time of blood pressure measurement.
Sitting
Sitting (for example on bed or chair) at the time of blood pressure measurement.
Reclining
Reclining at the time of blood pressure measurement.
Lying
Lying flat at the time of blood pressure measurement.
Tilt
The craniocaudal tilt of the surface on which the person is lying at the time of measurement.
Mean arterial pressure
The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle.
Pulse pressure
The difference between the systolic and diastolic pressure.
Small Adult
A cuff used for a small adult.
Paediatric/Child
A cuff that is appropriate for a child or adult with a thin arm.
Diastolic endpoint
Record which Korotkoff sound is used for determining diastolic pressure using auscultative method.
Phase IV
The fourth Korotkoff sound is identified as an abrupt muffling of sounds.
Phase V
The fifth Korotkoff sound is identified by absence of sounds as the cuff pressure drops below the diastolic blood pressure.
Lying with tilt to left
Lying flat with some lateral tilt, usually angled towards the left side. Commonly required in the last trimester of pregnancy to relieve aortocaval compression.
Infant
A cuff used for infants.
Neonatal
A cuff used for a neonate, assuming cuff is the appropriate size for maturity and birthweight of the neonate.
Right wrist
The right wrist of the individual.
Left wrist
The left wrist of the individual.
Device
Details about sphygmomanometer or other device used to measure the blood pressure.
Right ankle
The right ankle of the individual.
Exertion
Details about physical activity undertaken at the time of blood pressure measurement.
Left ankle
The left ankle of the individual.
Finger
A finger of the individual.
Method
Method of measurement of blood pressure.
Auscultation
Method of measuring blood pressure externally, using a stethoscope and Korotkoff sounds.
Palpation
Method of measuring blood pressure externally, using palpation (usually of the brachial or radial arteries).
Mean arterial pressure formula
Formula used to calculate the Mean Arterial Pressure (if recorded in data).
Machine
Method of measuring blood pressure externally, using a blood pressure machine.
Invasive
Method of measuring blood pressure internally ie involving penetration of the skin and measuring inside blood vessels.
24 hour average
Estimate of the average blood pressure over a 24 hour period.
Sleep status
Sleep status - supports interpretation of 24 hour ambulatory blood pressure records.
Awake
The individual is fully conscious.
Sleeping
The individual is in the natural state of bodily rest.
Toe
A toe of the individual.
Confounding factors
Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc.
Intra-arterial
Invasive measurement via transducer access line within an artery.
Systolic pressure formula
Formula used to calculate the systolic pressure from from mean arterial pressure (if recorded in data).
Diastolic pressure formula
Formula used to calculate the diastolic pressure from mean arterial pressure (if recorded in data).
Structured measurement location
Structured anatomical location of where the measurement was taken.
Extension
Additional information required to capture local context or to align with other reference models/formalisms.
Clinical interpretation
Single word, phrase or brief description that represents the clinical meaning and significance of the blood pressure measurement.
Dorsum of foot
The individual's dorsum of the foot.
mmHg
millimeters of mercury
SNOMED-CT
[SNOMED-CT(2003)::364090009]
SNOMED-CT
[SNOMED-CT(2003)::271649006]
SNOMED-CT
[SNOMED-CT(2003)::271650006]
SNOMED-CT
[SNOMED-CT(2003)::246153002]
OBSERVATION
true
true
false
false
0
1
at0000
data
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true
false
false
1
1
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HISTORY
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true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
EVENT
true
true
false
false
0
1
at0002
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
0
1
at0006
value
true
true
false
false
0
1
false
DV_PROPORTION
true
true
false
false
1
1
numerator
true
true
false
false
1
1
false
REAL
true
true
false
false
1
1
-
true
true
false
false
0.0
100.0
type
true
true
false
false
1
1
false
INTEGER
true
true
false
false
1
1
-
2
CLUSTER
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false
false
true
0
at0054
archetype_id/value matches {/openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0060
archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
0
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0014
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0034
archetype_id/value matches {/openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0015
archetype_id/value matches {/openEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0018
archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0059
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.pulse_oximetry.v1
Pulse oximetry
Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.
Event Series
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Tree
@ internal @
SpO₂
The saturation of oxygen in the peripheral blood, measured via pulse oximetry.
List
@ internal @
Sensor site
The site of the measurement sensor.
Tree
@ internal @
Inspired oxygen
Details of the amount of oxygen available to the subject at the time of observation.
Confounding factors
Comment on and record other incidental factors that may be affect interpretation of the observation.
Oximetry device
Details of the non-invasive oximetry device used.
Exertion
Details about physical activity undertaken at the time of measurement.
Comment
A text comment about the pulse oximetry result.
SpOC
The oxygen content of the peripheral blood, calculated based on pulse oximetry and pulse CO-oximetry.
SpCO
The saturation of carboxyhaemoglobin in the peripheral blood, measured via pulse CO-oximetry.
SpMet
The saturation of methaemoglobin in the peripheral blood, measured via pulse CO-oximetry.
Waveform
A waveform reading associated with the oximetry measurement.
Interpretation
Single word, phrase or brief description which represents the clinical meaning and significance of the measurements.
Extension
Additional information required to capture local context or to align with other reference models/formalisms.
Multimedia image
Details of a series of oximetry readings, other than waveforms, expressed as a multimedia image or series of images. Waveforms should be recorded using the Waveform slot and associated cluster archetype.
Pre/post-ductal
Sensor site relative to the ductus arteriosus in neonates, to determine whether the blood supply to limb of the sensor site is pre- or post-ductal in cases of patent ductus arteriosus.
Pre-ductal
The sensor site is pre-ductal.
Post-ductal
The sensor site is post-ductal.
Indeterminate
Unable to assess whether the sensor site is pre- or post-ductal.
SNOMED-CT
[SNOMED-CT::431314004]
SNOMED-CT
[SNOMED-CT::16206004]
SNOMED-CT
[SNOMED-CT::448703006]
SNOMED-CT
[SNOMED-CT::277923006]
LOINC
[LOINC::59408-5]
LOINC
[LOINC::20081-6]
LOINC
[LOINC::57800-5]
LOINC
[LOINC::86904-0]
LOINC
[LOINC::2614-6]
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
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false
1
1
at0001
events
true
true
false
false
0
1
false
EVENT
true
true
false
false
0
1
at0002
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
122
true
true
false
false
0.0
1000.0
cm
true
true
false
false
0.0
250.0
[in_i]
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0013
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0011
archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0022
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
true
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.height.v2
Height/Length
Height, or body length, is measured from crown of head to sole of foot.
history
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Simple
@ internal @
Height/Length
The length of the body from crown of head to sole of foot.
List
@ internal @
Device
Description of the device used to measure height or body length.
Tree
@ internal @
Position
Position of individual when measured.
Standing
Height is measured standing on both feet with weight distributed evenly, heels together and both buttocks and heels in contact with a vertical back board.
Comment
Additional narrative about the measurement, not captured in other fields.
Confounding factors
Narrative description of any issues or factors that may impact on the measurement.
Lying
Length is measured in a fully extended, recumbent position with the pelvis flat, legs extended and feet flexed.
Birth
Usually the first length measurement, recorded soon after birth. This event will only be used once per health record
.
Extension
Additional information required to capture local content or to align with other reference models/formalisms.
in
inch
LOINC
[LOINC::8302-2]
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0002
events
true
true
false
false
0
1
false
EVENT
true
true
false
false
0
1
at0003
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
124
true
true
false
false
0.0
1000.0
kg
true
true
false
false
0.0
2000.0
[lb_av]
true
true
false
false
0.0
1000000.0
g
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0008
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0015
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0020
archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0027
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
true
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.body_weight.v2
Body weight
Measurement of the body weight of an individual.
Simple
@ internal @
history
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Weight
The weight of the individual.
state structure
@ internal @
State of dress
Description of the state of dress of the person at the time of weighing.
Fully clothed, including shoes
Clothing which may add significantly to weight, including shoes.
Lightly clothed/underwear
Clothing which will not add to weight significantly.
Naked
Without any clothes.
protocol structure
@ internal @
Nappy/diaper
Wearing only a nappy - which may add significantly to weight.
Device
Details about the weighing device.
Comment
Additional narrative about the measurement of Body weight, not captured in other fields.
Confounding factors
Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
Birth
Usually the first weight, measured soon after birth. This event will only be used once per health record
.
Extension
Additional information required to capture local content or to align with other reference models/formalisms.
Fully clothed, without shoes
Clothing which may add significantly to weight.
lbm
pound mass
LOINC
[LOINC::29463-7]
false
false
true
false
false
true
1
openEHR-EHR-COMPOSITION.encounter.v1
vital_signs_basic.v1
vital_signs_basic.v1
Interaction, contact or care event between a subject of care and healthcare provider(s).
Tree
@ internal @
Extension
Additional information required to capture local context or to align with other reference models/formalisms.