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During breathing or respiration, air flows to and from the lungs, where gas exchange occurs, absorbing oxygen from the air into the blood and exhaling carbon dioxide into the air. Observations of spontaneous breathing, usually registered as part of the observation of vital functions.


An alert describes a clinical or administrative fact brought to the attention of the users of the clinical systems to be taken into account when shaping diagnostic and therapeutic policy or in dealing with the patient, usually because of a safety risk.  Disorders that describe the body’s sensitivity to a substance which results in a specific physiological reaction after being exposed to that substance are referred to as allergies. These are described in a separate information model. 


A general measurement determines the result of a measurement or determination made for a patient. The information model is used to record the measurement results for which no specific information models have yet been formulated. The information model is not intended for laboratory determinations to be carried out on the material taken from the patient.


An allergy or intolerance describes a patient’s tendency towards hypersensitivity to a certain substance, so that an unwanted physiological reaction is expected after exposure to the substance, while most people would not exhibit such a reaction to that amount. The observed physiological changes are usually the result of an immunological reaction.


The Apgar score represents the overall clinical status of a newborn child. This is evaluated one, five and ten minutes after birth based on 5 parameters: Appearance, Pulse, Grimace, Activity, Respiration. If the score measured at 5 minutes is < 8, the Apgar score is measured again at 10, 15, 20 minutes etc. until the score = 8.


The Barthel ADL index is a validated scale used to measure and track patients’ activities of daily living (ADL) and indirectly, the extent to which they are dependent on help. The list comprises 10 variables: bowels, bladder, grooming, toilet use, feeding, transfers (from chair to bed and vice versa), mobility, dressing, climbing stairs and bathing, which are all given a score. The total score is the sum of the scores of the 10 variables.


A treatment instruction includes an agreed constraint in the treatment based on the oral or written living will of the patient.


The blood pressure is a parameter for determining the condition of the blood circulation and is expressed in systolic and diastolic pressure in mmHg.


The functional or mental status provides insight into the patient’s functional and mental limitations.


Fifteen-point scale for expressing a person’s level of consciousness, from fully awake to deep unconsciousness, in a number: the so-called EMV score. The Glasgow Coma Scale score or EMV (Eye-Motor-Verbal) score is a scale to measure the extent of consciousness, based on eye, verbal and motor responses to specific prescribed sound and pain stimuli.


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