ARCHETYPE Examination of urethral meatus (openEHR-EHR-CLUSTER.exam_urethral_meatus.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_urethral_meatus.v0
ConceptExamination of urethral meatus
DescriptionFindings observed during physical examination of the urethral meatus and distal urethra.
UseUse to record a narrative description of the overall findings observed during the physical examination of the urethral meatus and distal urethra. 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_vulva and CLUSTER.exam_penis archetypes, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. 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 urethral meatus and distal urethra visible to the naked eye. To record findings about urethroscopy use CLUSTER.inspection_urethra. 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.urinalysis.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during physical examination of the urethral meatus and distal urethra that is visible to the naked eye.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2015-06-08
Other Details LanguageAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2015-06-08
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, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=F5A9924722F395CE821D5011D88AD457, build_uid=e6946ee7-abf7-4ed5-a5cc-2d1b8173779d, revision=0.0.1}
Keywords
Lifecyclerejected
UIDc782c6e6-5879-44aa-a323-b59c8e4f2f07
Language useden
Citeable Identifier1013.1.2097
Revision Number0.0.1
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during physical examination of the urethral meatus and distal urethra., archetypeConceptComment=null, otherContributors=Silje Ljosland Bakke, Nasjonal IKT, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway
Heather Leslie, Atomica Informatics, Australia, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], credentials=[], description=[], relationships=[], ism_transition=[], activities=[], 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[at0012], code=at0012, itemType=ELEMENT, level=1, text=Discharge presence, description=The presence or absence of urethral discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A urethral discharge is present.]
  • Absent [A urethral discharge is not present.]
  • Indeterminate [It is not possible to tell if a urethral discharge is present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0013], code=at0013, itemType=ELEMENT, level=1, text=Discharge type, description=Type of urethral discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Purulent [The urethral discharge is purulent in appearance.]
  • Mucopurulent [The urethral discharge is mucopurulent in appearance.]
  • Mucous [The urethral discharge is mucous in appearance.]
  • Clear [The urethral discharge is clear in appearance.]
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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:
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openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Caruncle, description=The presence or absence of caruncles., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A urethral caruncle is present.]
  • Absent [A urethral caruncle is not present.]
  • Indeterminate [It is not possible to tell if a urethral caruncle is present.]
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  • Present [A urethral discharge is present.]
  • Absent [A urethral discharge is not present.]
  • Indeterminate [It is not possible to tell if a urethral discharge is present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0013], code=at0013, itemType=ELEMENT, level=1, text=Discharge type, description=Type of urethral discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Purulent [The urethral discharge is purulent in appearance.]
  • Mucopurulent [The urethral discharge is mucopurulent in appearance.]
  • Mucous [The urethral discharge is mucous in appearance.]
  • Clear [The urethral discharge is clear in appearance.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about 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:
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  • Present [A urethral caruncle is present.]
  • Absent [A urethral caruncle is not present.]
  • Indeterminate [It is not possible to tell if a urethral caruncle is present.]
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