ARCHETYPE Examination of a lesion (openEHR-EHR-CLUSTER.exam_lesion.v0)

Name: Examination of a lesion
License: http://creativecommons.org/licenses/by-sa/3.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.exam_lesion.v0
Concept	Examination of a lesion
Description	Findings observed during the physical examination of an identified macroscopic localised structural change or damage to normal tissue.
Use	Use for recording findings observed during the physical examination of an identified macroscopic localised structural change or damage to normal tissue. This archetype is intended to be used to describe both benign and malignant lesions. This archetype is intended to be used to describe single localised lesions. To describe localised clusters of lesions such as a cluster of moles, use an appropriate CLUSTER archetype. This archetype may be nested inside such an archetype to describe single lesions which are part of the cluster. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the OBSERVATION.exam, CLUSTER.exam-skin or other CLUSTER.exam-archetypes, but can also be used within any other OBSERVATION, ACTION or CLUSTER archetypes, where clinically appropriate - for example, CLUSTER.exam-breast or CLUSTER.exam-penis. This archetype may be specialised to enable recording details only relevant to a subset of lesions. An example of this can be specialising the archetype for wounds/ulcers, to allow recording information about wound edges, wound bed, undermining, or exudate. 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 to record findings about an imaging lesion. Use the CLUSTER.imaging_exam-abnormality archetype for this purpose. Not to be used to record findings about non-localised or whole-organ eruptions such as a chickenpox rash covering the entire skin surface. Use the CLUSTER.symptom_sign archetype for this purpose. Not to be used to record a macroscopic pathology examination of a specimen from a lesion. Use an appropriate CLUSTER archetype within the OBSERVATION.laboratory_test_result archetype. Not to be used for recording the clinical history of a lesion - use specific OBSERVATION and CLUSTER archetypes, for example OBSERVATION.story and CLUSTER.symptom_sign.
Purpose	For recording findings observed during the physical examination of an identified macroscopic localised structural change or damage to normal tissue.
References	Derived from: Examination of a lesion, Draft archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2021-10-22]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.2109
Copyright	© Nasjonal IKT HF
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-25
Other Details Language	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-25
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=Nasjonal IKT, references=Derived from: Examination of a lesion, Draft archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2021-10-22]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.2109, current_contact=Heather Leslie, Atomica Informatics, original_namespace=no.nasjonalikt, original_publisher=Nasjonal IKT, custodian_namespace=no.nasjonalikt, MD5-CAM-1.0.1=A3BDBE1A73307DC1822D5345C80A1160, build_uid=9cff9ed1-b4f0-44c7-8edf-1ce524d66662, revision=0.0.1-alpha}
Keywords	injury, wound, ulcer, macule, papule, patch, plaque, vesicle, bulla, erosion, fissure, excoriation, nodule, tumor, tumour, burrow, pits, abscess, carbuncle, cyst, furuncle, pustule, vesicle, hematoma, haematoma, purpura, petechiae, telangiectasia, weal, wheal, urticaria, scale, atrophy, incision, incised, puncture, contusion, bruise, abrasion, laceration, maceration, burn, frostbite
Lifecycle	in_development
UID	920347ee-9598-4227-90cf-be3b04c28a1d
Language used	en
Citeable Identifier	1013.1.2109
Revision Number	0.0.1-alpha
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of an identified macroscopic localised structural change or damage to normal tissue., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators= Norwegian Bokmål: Silje Ljosland Bakke, Helse Vest IKT AS, silje.ljosland.bakke@helse-vest-ikt.no Portuguese (Brazil): Osmeire Sanzovo, Hospital Sírio Libanês, osmeire.acsanzovo@hsl.org.br , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], events=[], details=[], provider=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Lesion type, description=Identification of the type of lesion examined., comment='Lesion type' should be coded with a terminology, where possible. For example: mole, weal, depigmented area, laceration, haematoma, surgical incision, scar, basal cell carcinoma, venous leg ulcer or mucous membrane polyp. In some use cases known as 'primary morphology'., 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[at0015], code=at0015, itemType=ELEMENT, level=1, text=Shape, description=Identification of the shape of the lesion., comment='Shape' should be coded with a terminology, where possible. For example 'pedunculated' or 'circular'. In some use cases known as 'shape morphology' or 'secondary morphology'., 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=Label, description=Identification, by using a label, of the lesion to distinguish one lesion from similar lesions at the same body site., comment=For example, 'Mole #1' as marked on a diagram of the body site., 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[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[at0013], code=at0013, itemType=ELEMENT, level=1, text=(Length/diameter), description=The length or diameter of the lesion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length Units: >=0.0 mm >=0.0 cm >=0.0 in Runtime name constraint: at0022::Length [The length of the lesion.] at0023::Diameter [The diameter of the lesion.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Width, description=The width of the lesion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length Units: >=0.0 mm >=0.0 cm >=0.0 in , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=ELEMENT, level=1, text=(Height/depth), description=Height or depth of the lesion above or below the surrounding organ surface., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length Units: >=0.0 mm >=0.0 cm >=0.0 in Runtime name constraint: at0020::Height [Height of the lesion above the surrounding organ surface.] at0021::Depth [Depth of the lesion below the surrounding organ surface.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0024], code=at0024, itemType=ELEMENT, level=1, text=Area, description=The area of the lesion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Area Units: >=0.0 mm² >=0.0 cm² >=0.0 in² 0.0..100.0 % body , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Body site, description=Identification of the body site of the examined lesion., comment='Body site' should be coded with a terminology, where possible. For example: right knee, palate, sacrum or duodenum. If the body site is identified in the 'Structured body site' SLOT or in another archetype in which this archetype is nested, this data element may be redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured anatomical location of the examined lesion., comment=If the body site is identified in the 'Body site' element or in another archetype in which this archetype is nested, this data element may be redundant., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_relative.v2 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Additional details, description=Additional structured details about the examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, 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.media_file.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 examination findings., comment=The 'Clinical interpretation' can be coded with a terminology, where appropriate., 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 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]], description=[], protocol=[], ism_transition=[], context=[], data=[], activities=[], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, 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= (Cardinality: 1.., unordered), 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=Lesion type, description=Identification of the type of lesion examined., comment='Lesion type' should be coded with a terminology, where possible. For example: mole, weal, depigmented area, laceration, haematoma, surgical incision, scar, basal cell carcinoma, venous leg ulcer or mucous membrane polyp. In some use cases known as 'primary morphology'., 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[at0015], code=at0015, itemType=ELEMENT, level=1, text=Shape, description=Identification of the shape of the lesion., comment='Shape' should be coded with a terminology, where possible. For example 'pedunculated' or 'circular'. In some use cases known as 'shape morphology' or 'secondary morphology'., 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=Label, description=Identification, by using a label, of the lesion to distinguish one lesion from similar lesions at the same body site., comment=For example, 'Mole #1' as marked on a diagram of the body site., 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[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[at0013], code=at0013, itemType=ELEMENT, level=1, text=(Length/diameter), description=The length or diameter of the lesion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length Units: >=0.0 mm >=0.0 cm >=0.0 in Runtime name constraint: at0022::Length [The length of the lesion.] at0023::Diameter [The diameter of the lesion.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Width, description=The width of the lesion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length Units: >=0.0 mm >=0.0 cm >=0.0 in , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=ELEMENT, level=1, text=(Height/depth), description=Height or depth of the lesion above or below the surrounding organ surface., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length Units: >=0.0 mm >=0.0 cm >=0.0 in Runtime name constraint: at0020::Height [Height of the lesion above the surrounding organ surface.] at0021::Depth [Depth of the lesion below the surrounding organ surface.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0024], code=at0024, itemType=ELEMENT, level=1, text=Area, description=The area of the lesion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Area Units: >=0.0 mm² >=0.0 cm² >=0.0 in² 0.0..100.0 % body , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Body site, description=Identification of the body site of the examined lesion., comment='Body site' should be coded with a terminology, where possible. For example: right knee, palate, sacrum or duodenum. If the body site is identified in the 'Structured body site' SLOT or in another archetype in which this archetype is nested, this data element may be redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured anatomical location of the examined lesion., comment=If the body site is identified in the 'Body site' element or in another archetype in which this archetype is nested, this data element may be redundant., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_relative.v2 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Additional details, description=Additional structured details about the examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, 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.media_file.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 examination findings., comment=The 'Clinical interpretation' can be coded with a terminology, where appropriate., 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 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]], minIndents={}, termBindingRetrievalErrorMessage=null]