| ARCHETYPE ID | openEHR-EHR-CLUSTER.auscultation_lung.v0 |
|---|---|
| Concept | Auscultation of lung |
| Description | Findings observed during the auscultation of a lung structure. |
| Use | Use to record a narrative description of the overall findings and clinical interpretation of observations made during auscultation of the lung. This initial draft archetype consists only of the core examination pattern data elements (as per CLUSTER.exam_pattern) and will likely be expanded further over time as specific clinical requirements are identified. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_lung archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate - for example, CLUSTER.exam_heart. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. |
| Misuse | Not to be used for recording data not related to the auscultation of the lungs. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure or OBSERVATION.imaging_exam. |
| Purpose | For recording a narrative description and clinical interpretation of the findings observed during the auscultation of both lungs together, a specified lung or a specified part of a lung. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-06-22 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-06-22 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | rejected |
| UID | fea69631-eb34-4576-a165-32432788bd6c |
| Language used | en |
| Citeable Identifier | 1013.1.2062 |
| Revision Number | 0.0.1 |
| items | |
| Lung structure examined | Lung structure examined: Identification of the lung structure under auscultation. For example: both lungs together; left lung; or right upper lobe. This data element should be coded using a terminology, if available. If the structure of the lung being examined has previously been identified in another archetype in which this archetype is nested, this data element becomes redundant. |
| No abnormality detected | No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination. Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. Allowed values: {true} |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| Multimedia representation | Multimedia representation: Audio file representing the physical examination findings. Include: openEHR-EHR-CLUSTER.multimedia.v1 and specialisations |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| Exam not done | Exam not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | Silje Ljosland Bakke, Bergen Hospital Trust, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom John Tore Valand, Haukeland Universitetssjukehus, Norway Heather Leslie, Ocean Informatics, Australia |
| Translators |