ARCHETYPE Palpation of rectum (openEHR-EHR-CLUSTER.palpation_rectum.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.palpation_rectum.v0
ConceptPalpation of rectum
DescriptionFindings observed during the palpation of the rectum.
UseUse to record a narrative description of the overall findings observed during the palpation of the rectum. This archetype consists of core examination pattern data elements and may 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. 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, a Digital Rectal Examination (DRE) can be represented by inserting CLUSTER.palpation_prostate or CLUSTER.palpation_cervix into the Examination findings SLOT in this archetype. 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 palpation of the rectum. 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 palpation of the rectum.
References
Copyright© openEHR Foundation, Nasjonal IKT HF
AuthorsAuthor name: Silje Ljosland Bakke
Organisation: National ICT Norway
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2015-09-17
Other Details LanguageAuthor name: Silje Ljosland Bakke
Organisation: National ICT Norway
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2015-09-17
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, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=D97F35405BBCB4498E29D320D9CCDB23, build_uid=fd2673d3-cc83-432f-a796-e5ff26323128, revision=0.0.1-alpha}
Keywordspalpation, rectal, anal, DRE, digital
Lifecyclein_development
UID8f6cfff6-4f12-4c74-83da-6174608580d1
Language useden
Citeable Identifier1013.1.2232
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the palpation of the rectum., archetypeConceptComment=null, otherContributors=Morten Aas, Oslo Universitetssykehus, Norway
Tomas Alme, DIPS ASA, Norway
Ole Andreas Bjordal, Webmed, Norway
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Kristian Berg, Universitetssykehuset Nord Norge, Norway
Bjørn Christensen, Helse Bergen HF, Norway
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Gunn Elin Blakkisrud, DIPS ASA, Norway
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Susanna Jönsson, Landstinget i Värmland, Sweden
Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Hallvard Lærum, Direktoratet for e-helse, Norway
Siv Marie Lien, DIPS ASA, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Harald Moi, Oslo universitetssykehus, professor emeritus, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Anne Olaug Olsen, Oslo universitetssykehus HF, Norway
Andrej Orel, Marand d.o.o., Slovenia
Navin Ramachandran, NHS, United Kingdom
Tanja Riise, Nasjonal IKT HF, Norway
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators=Norwegian Bokmål: Vebjørn Arntzen, Oslo universitetssykehus HF, varntzen@ous-hf.no, RN, Enterprise Architect
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