| ARCHETYPE ID | openEHR-EHR-CLUSTER.palpation_testicle.v0 |
|---|---|
| Concept | Palpation of a testicle |
| Description | Findings observed during the palpation of a testicle. |
| Use | Use to record a narrative description of the overall findings observed during the palpation of a testicle. 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_scrotum archetype, 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. |
| Misuse | Not to be used for recording data not related to the physical examination of a testicle. 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 physical examination of XYZ. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Date originally authored: 2015-06-08 |
| Other Details Language | Date originally authored: 2015-06-08 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | rejected |
| UID | 85c46a24-1e60-4f81-a9a0-52f2fd9afe78 |
| Language used | en |
| Citeable Identifier | 1013.1.2100 |
| Revision Number | 0.0.1 |
| items | |
| Testicle examined | Testicle examined: Identification of the XYZ under examination.
|
| 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} |
| Present | Present: The specified testicle is present. |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| Examination findings | Examination findings: Structured details about the physical examination findings. Include: All not explicitly excluded archetypes |
| Multimedia representation | Multimedia representation: Digital image, video or diagram 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. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Tenderness | Tenderness: The examined testicle is tender. |
| Swelling | Swelling: The examined testicle is swollen. |
| 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 |