ARCHETYPE Examination of cranial nerves (openEHR-EHR-CLUSTER.exam_cranial_nerves.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_cranial_nerves.v0
ConceptExamination of cranial nerves
DescriptionFindings observed during the physical examination of the cranial nerves.
UseUse to record a narrative description of the overall findings observed during the physical examination of the cranial nerves. 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_nervous_system archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. 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 the clinical history about cranial nerve function - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical measurements or test results. Visual acuity testing should be captured using OBSERVATION.visual.field.measurement. Visual acuity test results should be captured using OBSERVATION.visual.acuity.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-06-24
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-06-24
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Ocean Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=51C1436A113F78019E054D35ECBF198D, build_uid=f244d319-6a40-4a03-8dee-cd13e228e98c, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID4a0e9bfb-a896-47ea-8622-918cd429c947
Language useden
Citeable Identifier1013.1.2094
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of the cranial nerves., archetypeConceptComment=null, otherContributors=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, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={details=[], identities=[], source=[], credentials=[], context=[], description=[], ism_transition=[], events=[], content=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0009], code=at0009, itemType=SLOT, level=1, text=I, description=Details about function of the olfactory nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_smell.v0 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0010], code=at0010, itemType=SLOT, level=1, text=II, description=Details about the function of the optic nerve., comment=Visual acuity testing should be captured using OBSERVATION.visual.field.measurement. Visual acuity test results should be captured using OBSERVATION.visual.acuity., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_retina.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=SLOT, level=1, text=III, IV & VI, description=Details about the function of the oculomotor, trochlear and abducens nerves., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_eyes.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_eom.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_eye.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=SLOT, level=1, text=V, description=Details about the function of the trigeminal nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_nerve_sensation.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_muscle.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0013], code=at0013, itemType=ELEMENT, level=1, text=Corneal reflex, description=Response elicited by stimulation of the cornea., comment=Also known as the Blink reflex. Provides information about the function of V and VII., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The corneal reflex is present.]
  • Absent [The corneal reflex is absent.]
  • Equivocal [It is not possible to determine if the corneal reflex is clearly present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0017], code=at0017, itemType=ELEMENT, level=1, text=Jaw jerk, description=Response to tapping chin with a reflex hammer., comment=Also known as the Masseter reflex., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The jaw jerk is present.]
  • Absent [The jaw jerk is absent.]
  • Equivocal [It is not possible to determine if the jaw jerk is clearly present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0021], code=at0021, itemType=SLOT, level=1, text=VII, description=Details about the function of the facial nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_face.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_muscle.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_taste.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022], code=at0022, itemType=SLOT, level=1, text=VIII, description=Details about the function of the vestibulococchlear nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_ears.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=SLOT, level=1, text=IX & X, description=Details about the function of the glossopharyngeal and vagus nerves., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_throat.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0024], code=at0024, itemType=ELEMENT, level=1, text=Pharyngeal reflex, description=Response elicited by stimulation of the roof of the mouth, back of tongue, tonsils, uvula and the throat., comment=Also known as the Gag reflex., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The pharyngeal reflex is present.]
  • Absent [The pharyngeal reflex is absent.]
  • Equivocal [It is not possible to determine if the pharyngeal reflex is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0028], code=at0028, itemType=ELEMENT, level=1, text=Pharyngeal reflex description, description=Narrative description about the pharyngeal reflex., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0029], code=at0029, itemType=SLOT, level=1, text=XI, description=Details about the function of the accessory nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_muscle.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0030], code=at0030, itemType=SLOT, level=1, text=XII, description=Details about the function of the hypoglossal nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_tongue.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Additional findings, description=Structured details about other physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null]], capabilities=[], other_participations=[], contacts=[], target=[], data=[], relationships=[], state=[], protocol=[], activities=[], provider=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0009], code=at0009, itemType=SLOT, level=1, text=I, description=Details about function of the olfactory nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_smell.v0 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0010], code=at0010, itemType=SLOT, level=1, text=II, description=Details about the function of the optic nerve., comment=Visual acuity testing should be captured using OBSERVATION.visual.field.measurement. Visual acuity test results should be captured using OBSERVATION.visual.acuity., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_retina.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=SLOT, level=1, text=III, IV & VI, description=Details about the function of the oculomotor, trochlear and abducens nerves., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_eyes.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_eom.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_eye.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=SLOT, level=1, text=V, description=Details about the function of the trigeminal nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_nerve_sensation.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_muscle.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0013], code=at0013, itemType=ELEMENT, level=1, text=Corneal reflex, description=Response elicited by stimulation of the cornea., comment=Also known as the Blink reflex. Provides information about the function of V and VII., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The corneal reflex is present.]
  • Absent [The corneal reflex is absent.]
  • Equivocal [It is not possible to determine if the corneal reflex is clearly present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0017], code=at0017, itemType=ELEMENT, level=1, text=Jaw jerk, description=Response to tapping chin with a reflex hammer., comment=Also known as the Masseter reflex., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The jaw jerk is present.]
  • Absent [The jaw jerk is absent.]
  • Equivocal [It is not possible to determine if the jaw jerk is clearly present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0021], code=at0021, itemType=SLOT, level=1, text=VII, description=Details about the function of the facial nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_face.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_muscle.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_taste.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022], code=at0022, itemType=SLOT, level=1, text=VIII, description=Details about the function of the vestibulococchlear nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_ears.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=SLOT, level=1, text=IX & X, description=Details about the function of the glossopharyngeal and vagus nerves., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_throat.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0024], code=at0024, itemType=ELEMENT, level=1, text=Pharyngeal reflex, description=Response elicited by stimulation of the roof of the mouth, back of tongue, tonsils, uvula and the throat., comment=Also known as the Gag reflex., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The pharyngeal reflex is present.]
  • Absent [The pharyngeal reflex is absent.]
  • Equivocal [It is not possible to determine if the pharyngeal reflex is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0028], code=at0028, itemType=ELEMENT, level=1, text=Pharyngeal reflex description, description=Narrative description about the pharyngeal reflex., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0029], code=at0029, itemType=SLOT, level=1, text=XI, description=Details about the function of the accessory nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_muscle.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0030], code=at0030, itemType=SLOT, level=1, text=XII, description=Details about the function of the hypoglossal nerve., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_tongue.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Additional findings, description=Structured details about other physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]