ARCHETYPE Examination of a lung (openEHR-EHR-CLUSTER.exam_lung.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_lung.v0
ConceptExamination of a lung
DescriptionFindings observed during the physical examination of a single lung.
UseUse to record a narrative description of the overall findings observed during the physical examination of a single 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_chest archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. Record findings of the second lung in a second instance of this archetype within the same SLOT. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, CLUSTER.auscultation_lung. 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.
MisuseNot to be used for recording data not related to the physical examination 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.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the physical examination of a lung.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-06-22
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-06-22
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=C3BFA654F4DC2BCF942E29895086BB62, build_uid=ce56df5c-7d09-404f-ba1f-6ff783ce15d2, revision=0.0.1}
Keywords
Lifecyclerejected
UID46b35486-a744-4c31-b874-37480c508304
Language useden
Citeable Identifier1013.1.2063
Revision Number0.0.1
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Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway
Heather Leslie, Ocean Informatics, Australia, originalLanguage=en, translators=Norwegian Bokmål: Anca Heyd, DIPS ASA, Ahe@Dips.No: ahe@dips.no
Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP - Brasil, osmeire.acsanzovo@hsl.org.br
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  • Right [The right lung was examined.]
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  • Right [The right lung was examined.]
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