ARCHETYPE Exclusion of examination (openEHR-EHR-CLUSTER.exclusion_exam.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exclusion_exam.v1
ConceptExclusion of examination
DescriptionPositive statement to record that a physical examination or clinical test was not performed.
UseUse to record that a physical examination or clinical test was not performed, with an optional statement about the reason for the non-performance. This archetype has been designed to be used to allow recording of 'no examination was done' at multiple levels of the examination process. It will never be used as a stand-alone archetype but always inside an examination archetype that provides the context for the examination being performed. For example, insertion of this archetype into the Examination Detail' SLOT within OBSERVATION.exam allows for recording that no physical examination was performed. Similarly, insertion of this archetype into the Details SLOT of any examination-related CLUSTER archetype, such as CLUSTER.exam_eye_pupil, allows recording that no physical examination was performed only for examination of a specified pupil, perhaps because a facial injury prevented the pupil being visualised. This archetype may also be used within other OBSERVATION, or relevent CLUSTER, archetypes to allow recording of the inability to test or measure other clinical findings. For example: OBSERVATION.audiogram or OBSERVATION.cgas. In particular, this archetype has specifically been designed to avoid the need to use flags or terminology to express negation about a record of physical examination or clinical findings within the health record. It is reasonable to assume that if the examination or clinical assessment was partially performed, then only data about the component successfully performed will be recorded.
MisuseNot to be used to record the details about clinical findings observed on physical examination or during clinical testing. Use specific archetypes for these purposes. Not to be used to record the exclusion or absence of adverse reactions, family history, medication use, procedures, problems or diagnoses - use EVALUATION.exclusion_global or EVALUATION.exclusion_specific for this purpose.
PurposeTo record that a physical examination or clinical test was not performed.
ReferencesExclusion of examination, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-22]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1383
Copyright© Australian Digital Health Agency, openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-01-14
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-01-14
OtherDetails Language Independent{custodian_organisation=openEHR Foundation, references=Exclusion of examination, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-22]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1383, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=2DCECCDEA74C4AD5B9B0F6087F57BE61, build_uid=9ebf8286-e78c-40e5-bb9f-01b54114b662, revision=1.1.1}
Keywordsexclusion, exam, examination, done, performed
Lifecyclepublished
UID6c9ede6d-923b-4b22-9005-3fdf4e853a0c
Language useden
Citeable Identifier1013.1.1846
Revision Number1.1.1
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Positive statement to record that a physical examination or clinical test was not performed., archetypeConceptComment=null, otherContributors=Vebjoern Arntzen, Oslo university hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, National ICT Norway, Norway (openEHR Editor)
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Evelyn Hovenga, EJSH Consulting, Australia
Lars Karlsen, DIPS ASA, Norway
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Bjoern Naess, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia, originalLanguage=en, translators=German: Ramona Wellmann, Medizinische Hochschule Hannover, wellmann.ramona@mh-hannover.de
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