| ARCHETYPE ID | openEHR-EHR-CLUSTER.inspection_vagina.v0 |
|---|---|
| Concept | Inspection of vagina |
| Description | Findings observed during the inspection of the vagina. |
| Use | Use to record a narrative description of the overall findings observed during the inspection of the vagina, especially during a speculum examination.. 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 detail' SLOT within the OBSERVATION.exam archetype, but can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate - for example, CLUSTER.exam_vulva. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, CLUSTER.inspection_cervix. 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 inspection of the vagina. 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 inspection component of a physical examination of the vagina. |
| References | |
| Copyright | © openEHR Foundation |
| 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 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | rejected |
| UID | c87a0f61-1dea-4586-841f-4d1c1817a6d6 |
| Language used | en |
| Citeable Identifier | 1013.1.2114 |
| Revision Number | 0.0.1 |
| items | |
| 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} |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| Currently menstruating | Currently menstruating: Evidence of menstruation is observed at time of inspection. 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} |
| Examination findings | Examination findings: Structured details about the physical examination findings. Include: openEHR-EHR-CLUSTER.inspection_ openEHR-EHR-CLUSTER.exam_ openEHR-EHR-CLUSTER.exam_ |
| 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. For example, noting recent removal of tampon. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | 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 |
| Translators |