ARCHETYPE Examination Findings - Lens (openEHR-EHR-CLUSTER.exam_lens.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_lens.v1
ConceptExamination Findings - Lens
DescriptionFindings on physical examination of the lens of the eye.
UseUse to record the findings on physical examination of the lens of the eye. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Description' data element. Specifically designed to be used within the OBSERVATION.exam archetype, but may be used within any clinically appropriate ENTRY or CLUSTER archetype.
MisuseNot to be used to record findings of the physical examination of other parts of the eye, such as the retina or conjunctiva - use other specific archetypes for this purpose.
PurposeFor recording the findings on physical examination of the lens.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2013-03-01
Other Details LanguageAuthor name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2013-03-01
Other Details (Language Independent)
  • MD5-CAM-1.0.1: 9416B8BF7089D7E5681BD12DC0FC005A
Keywordseye, examination, physical, cataract
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.1403
items
Eye ExaminedEye Examined: The eye examined.
  • Left eye [The left eye was examined.]
  • Right eye [The right eye was examined.]
Lens OpacityLens Opacity: The morphology of the lens / or cataract.
Choice of:
  •  Coded Text
    • Normal, clear crystalline lens [The lens is normal, clear and crystalline.]
    • Early opacity [A hazy, early opacity is visible.]
    • Nuclear sclerosis [Nucelar sclerosia is present.]
    • Brunescent nucleus [A brunescent catract nucleus is present.]
    • Mature (white cortex) cataract [A mature cataract is present.]
    • Hypermature / Morgagnian cataract [A hypermature, Morgagnian catarct is present.]
    • Watercleft cataract [A watercleft cataract is present.]
    • Retrodot cataract [A retrodot cataract is present.]
    • Diffuse opacities [Multiple diffuse lens opacities are visible.]
    • Pseudophakia [Psedophakia is present.]
  •  Text
Lens PositionLens Position: The position of the lens.
  • Normal [The lens is in a normal position.]
  • Subluxation [The lens shows subluxation.]
  • Dislocation [The lens is dislocated into the vitreous.]
Cataract MaturityCataract Maturity: The maturity of cataract development.
  • None [There is no cataract present.]
  • Early [The cataract is at an early stage of maturity.]
  • Moderate [A moderate cataract is present.]
  • Mature [A mature cataract is present.]
Posterior Capsule FibrosisPosterior Capsule Fibrosis: The degree of posterior lens capsule fibrosis.
  • Absent / clear [There is no evidence of posterior capsule fibrosis]
  • Mild fibrosis (+) [Mild posterior capsule fibrosis is evident.]
  • Moderate fibrosis (++) [Moderate posterior capsule fibrosis is evident.]
  • Severe fibrosis (+++) [Severe posterior capsule fibrosis is evident.]
Cataract LocationCataract Location: The location of the catract identified.
  • Cortical cataract [A cortical cataract is present.]
  • Posterior sub capsular cataract [A posterior sub-capsular cataract is present.]
  • Coronary cataract [A coronary cataract is present.]
  • Polar cataract [A polar cataract is present.]
  • Lamellar cataract [A lamellar cataract is present.]
  • Nuclear cataract [The cataract is located in the nucleus.]
  • Nucelo-cortical cataract [The cataract is located in a nucelo-cortical position.]
InterpretationInterpretation: An interpretation of the lens examination findings, preferably coded.
DescriptionDescription: An overall narrative description of findings of examination of the lens.
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