ARCHETYPE Examination of skin (openEHR-EHR-CLUSTER.exam_skin.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_skin.v0
ConceptExamination of skin
DescriptionFindings observed during the physical examination of an area of skin.
UseUse to record a description of the overall findings observed during the physical examination of an area of skin. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within many of the CLUSTER archetypes for examination of various regions or anatomical structures - for example, CLUSTER.exam_abdomen or CLUSTER.exam_breast - but can also be used within the OBSERVATION.exam. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. 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 skin. 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 description and clinical interpretation of the findings observed during the physical examination of an identified area of skin.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT HF, Norway
Date originally authored: 2015-06-08
Other Details LanguageAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT HF, Norway
Date originally authored: 2015-06-08
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, current_contact=Heather Leslie, Ocean Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=5033749CC05FB1D564E862C80E6D2633, build_uid=e645f61b-54b7-4d83-8983-88b167bb2e52, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID90f5e49f-48be-4d04-ba90-257d24bcbcb1
Language useden
Citeable Identifier1013.1.2096
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of an area of skin., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør)
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør), originalLanguage=en, translators=Norwegian Bokmål: John Tore Valand, Silje Ljosland Bakke, Vebjørn Arntzen, Helse Bergen HF, Nasjonal IKT HF, Oslo universitetsykehus HF
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openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
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  • Present [The finding is observed to be present.]
  • Absent [The finding is not observed to be present.]
  • Indeterminate [It is not able to be determined if the finding is present or absent..]
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openEHR-EHR-CLUSTER.exam_skin.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_wound.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_lesion.v0 and specialisations, 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:
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openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
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  • Present [The finding is observed to be present.]
  • Absent [The finding is not observed to be present.]
  • Indeterminate [It is not able to be determined if the finding is present or absent..]
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openEHR-EHR-CLUSTER.exam_skin.v0 and specialisations Or
openEHR-EHR-CLUSTER.exam_wound.v0 and specialisations Or
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