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

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_lesion.v0
ConceptExamination of a lesion
DescriptionFindings observed during the physical examination of an identified lesion.
UseUse to record a narrative description of the overall findings observed during the physical examination of an identified lesion. 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_skin archetype or the OBSERVATION.exam, but can also be used within any other OBSERVATION or CLUSTER archetypes, where clinically appropriate - for example, CLUSTER.exam_breast or CLUSTER.exam_penis. 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 an identified lesion. 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 narrative description and clinical interpretation of the findings observed during the physical examination of an identified lesion.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-06-25
Other Details LanguageAuthor 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=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=FC08A47619EFC4E271F5ADFB1808A217, build_uid=2855eb1c-e592-4a90-87ec-2c4df3ae6fd8, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID920347ee-9598-4227-90cf-be3b04c28a1d
Language useden
Citeable Identifier1013.1.2109
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of an identified lesion., 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, Atomica Informatics, Australia, originalLanguage=en, translators=Portuguese (Brazil): Osmeire Sanzovo, Hospital Sírio Libanês, osmeire.acsanzovo@hsl.org.br
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