ARCHETYPE Examination Findings – Posterior Chamber of eye (openEHR-EHR-CLUSTER.exam_posterior_chamber.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_posterior_chamber.v1
ConceptExamination Findings – Posterior Chamber of eye
DescriptionFindings on examination of the posterior chamber of the eye which could have clinical relevance
UseIt can be attached to an OBSERVATION type archetypes whenever thay are related to clinical tests studying the posterior chamber of the eye. For example, attached to "OBSERVATION.fundoscopic_examination" it would provide additional information about the findings when examining an eye fundus. Could also be used with "OBSERVATION.ophthalmic_tomography_examination", providing information about findings during an OCT study. This archetype is applied to describe structural findings detected objectively when reviewing images from the posterior chamber of the eye. Therefore, the aim is registering symptoms concerning eye disorders that could have diagnostic interest.
MisuseNot to be used to record findings of the examination of other parts of the eye besides the posterior chamber. Do not get confused with "examination_details" archetypes, which register information about test acquisition, quality, artifacts, ... It should not be used to include subjective findings. There are specific EVALUATION type archetypes for this purpose.
PurposeTo record the clinical findings on examination of the posterior chamber of the eye.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Aitor Eguzkitza
Organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra
Email: aitor.eguzkiza@unavarra.es
Date originally authored: 2014-03-18
Other Details LanguageAuthor name: Aitor Eguzkitza
Organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra
Email: aitor.eguzkiza@unavarra.es
Date originally authored: 2014-03-18
OtherDetails Language Independent{MD5-CAM-1.0.1=CCF202D669778AFE5FF32C119EEF56A8}
Keywordseye, posterior chamber, examination
LifecycleOrganisationDraft
Language useden
Citeable Identifier1013.1.1610
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  • Flame haemorrhage [Flame or superficial retinal haemorrhage is present]
    [SNOMED-CT::247132001] (Retinal flame hemorrhage (disorder))
  • Deep haemorrhage [Deep retinal haemorrhage is present]
    [SNOMED-CT::48742005] (Deep retinal hemorrhage (finding))
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  • Mild DME [Some retinal thickening or hard exudates in posterior pole but distant from the center of the macula (not clinically significant edema)]
    [SNOMED-CT::399864000] (Diabetic macular edema not clinically significant (disorder))
  • Moderate DME [Retinal thickening or hard exudates approaching the center of the macula but not involving the center (clinically significant edema)]
    [SNOMED-CT::312911008] (Clinically significant macular edema (disorder))
  • Severe DME [Retinal thickening or hard exudates involving the center of the macula (clinically significant edema)]
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  • No haemorrhage [Aparently no retinal haemorrhage]
  • Flame haemorrhage [Flame or superficial retinal haemorrhage is present]
    [SNOMED-CT::247132001] (Retinal flame hemorrhage (disorder))
  • Deep haemorrhage [Deep retinal haemorrhage is present]
    [SNOMED-CT::48742005] (Deep retinal hemorrhage (finding))
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  • DME apparently absent [No apparent retinal thickening or hard exudates in posterior pole]
  • Mild DME [Some retinal thickening or hard exudates in posterior pole but distant from the center of the macula (not clinically significant edema)]
    [SNOMED-CT::399864000] (Diabetic macular edema not clinically significant (disorder))
  • Moderate DME [Retinal thickening or hard exudates approaching the center of the macula but not involving the center (clinically significant edema)]
    [SNOMED-CT::312911008] (Clinically significant macular edema (disorder))
  • Severe DME [Retinal thickening or hard exudates involving the center of the macula (clinically significant edema)]
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