ARCHETYPE Inspection of sputum (openEHR-EHR-CLUSTER.inspection_body_fluid-sputum.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.inspection_body_fluid-sputum.v0
ConceptInspection of sputum
DescriptionFindings observed during the macroscopic inspection of sputum.
UseUse to record a narrative description, structured details and clinical interpretation about findings observed during the inspection (including odour) of sputum. This archetype has been specifically designed to be used as the framework for recording details about examination of sputum. It may be used: - in the 'Examination findings' SLOT within many of the CLUSTER.exam family of archetypes and related inspection archetypes; - in the 'Physical properties' SLOT within the CLUSTER.specimen archetype; and - within other OBSERVATION or CLUSTER archetypes, where clinically appropriate. 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. While this archetype will most likely be used in the context of a living subject, it is also appropriate to use in recording autopsy findings. 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 to record the inspection of body fluids other than sputum - use the parent CLUSTER.inspection_body_fluid or other appropriate specialisations for this purpose. Not to be used to record the inspection of blood or blood clots, but only to record the presence of blood or blood clots within sputum. Not to be used for recording measurements of sputum volume - use OBSERVATION archetypes for this purpose. For example: OBSERVATION.fluid_output. Not to be used to record details about a non-physiological fluid. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example: OBSERVATION.story and CLUSTER.symptom_sign.
PurposeTo record the findings observed during the macroscopic inspection (including odour) of sputum.
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 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., 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=FD0B806F2040EC6B5C1087EF1F842C6A, build_uid=7e6fa172-db89-4024-a0e1-296bded46223, revision=0.0.1-alpha}
Keywordssputum, phlegm, mucus, airway, cough, haemoptysis, hemoptysis
Lifecyclein_development
UIDc641a63d-c6a9-4994-9fb1-fc926de84136
Language useden
Citeable Identifier1013.1.2841
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the macroscopic inspection of sputum., archetypeConceptComment=null, otherContributors=Morten Aas, Oslo Universitetssykehus, Norway
Kerstin Adolfsson, Sweden
Stine Nyheim Andreassen, DIPS ASA, Norway
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør)
Kristian Berg, Universitetssykehuset Nord Norge, Norway
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Kate Bryan, Stalis Ltd, United Kingdom
David Burns, East Kent Hospitals University Foundation NHS Trust, United Kingdom
B Christensen, HUS, Norway
Peter Coates, NHS England, United Kingdom
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Kristian Heldal, Telemark Hospital Trust, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Tom Jarl Jakobsen, Helse Bergen, Norway
Lars Karlsen, DIPS ASA, Norway
Dave Kilroy, Application Insight Ltd, United Kingdom
Shinji Kobayashi, Kyoto University, Japan
Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Siv Marie Lien, DIPS ASA, Norway
Kelvin Lok, Stalis Ltd, United Kingdom
Ole Kristian Losvik, Losol AS, Norway
Mark McEvoy, SITS International, Sweden
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Lars Ivar Mehlum, Helse Bergen HF, Norway
Colin Newell, OpusVL, United Kingdom
Andrej Orel, Marand d.o.o., Slovenia
Rob Organ, Yeovil District Hospital NHS Foundation Trust, United Kingdom
Petra Palm, Region Östergötland, Sweden
Mike Pargeter, Across Health Ltd, United Kingdom
Martin Paulson, Sykehuset i Vestfold, Norway
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
John Pyle, self, United Kingdom
Navin Ramachandran, NHS, United Kingdom
Cecilia Revelj, Landstinget i Kalmar län, Sweden
Ingela Sammeli, Landstinget i Värmland, Sweden
Elin Tell, Region Ostergotland, Sweden
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Lina Öfverström, Region Östergötland, Sweden, originalLanguage=en, translators=Norwegian Bokmål: Kristian Berg, John Tore Valand, Helse Nord, Helse Vest
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={credentials=[], details=[], source=[], description=[], protocol=[], content=[], state=[], identities=[], events=[], relationships=[], data=[], contacts=[], capabilities=[], target=[], ism_transition=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=1, text=Fluid name, description=The name of the body fluid being examined., comment=Coding of the 'Fluid name' with a coding system is desirable, if available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Sputum [Sputum is examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Description, description=Narrative description about the fluid., 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[at0.5], code=at0.5, itemType=ELEMENT, level=1, text=Appearance, description=The appearance of the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Mucoid [The sputum consists mostly of mucus.]
  • Mucopurulent [The sputum consists of both mucus and pus.]
  • Purulent [The sputum consists mostly of pus.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.2], code=at0.2, itemType=ELEMENT, level=1, text=Consistency, description=The viscosity of the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thin [Low viscosity; flowing relatively freely.]
  • Thick [Relatively firm or viscous; not flowing freely.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018.1], code=at0018.1, itemType=ELEMENT, level=1, text=Colour, description=The colour of the body fluid., comment=The intent of this data element is to record either a narrative description of the colour or to select one or more codes from a value set, appropriate to the body fluid, in a template., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Clear [Appears transparent.]
  • White [Pale or off white.]
  • Grey [Shade between white and charcoal, like ash.]
  • Yellow [Shade between cream and mustard.]
  • Green [Shade between pale honeydew and olive.]
  • Rust [Shade between red and brown.]
  • Brown [Shade between light tan and chocolate.]
  • Pink [Shade between pale pink and watermelon.]
  • Black [Shade between dark grey and jet black.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0017], code=at0017, itemType=ELEMENT, level=1, text=Odour, description=The smell of the body fluid., comment=The intent of this data element is to record either a narrative description of the odour, or to code with a value set where appropriate in a template., 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[at0022], code=at0022, itemType=ELEMENT, level=1, text=Blood, description=The qualitative amount of blood observed in the body fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Absent [No blood is observed in the fluid.]
  • Slight [There is a slight amount of blood observed.]
  • Moderate [There is a moderate amount of blood observed.]
  • Large [There is a large amount of blood observed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0021.1], code=at0021.1, itemType=ELEMENT, level=1, text=Blood clots, description=Blood clots are observed within or associated with the body fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Blood clots are present.]
  • Absent [Blood clots are absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Specific findings, description=Additional structured details about the body fluid., comment=For example: inclusion of detailed CLUSTER archetypes to record details about specific fluids such as clear fluids; or inclusion of further CLUSTER.exam_body_fluid archetypes could describe components of substances such as required to describe a mixture of blood and meconium post childbirth., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.physical_properties.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the inspection 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.multimedia.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=null, 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 inspection 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], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., 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.exclusion_exam.v1 and specialisations, extendedValues=null]], activities=[], context=[], provider=[], other_participations=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000.1, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=1, text=Fluid name, description=The name of the body fluid being examined., comment=Coding of the 'Fluid name' with a coding system is desirable, if available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Sputum [Sputum is examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Description, description=Narrative description about the fluid., 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[at0.5], code=at0.5, itemType=ELEMENT, level=1, text=Appearance, description=The appearance of the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Mucoid [The sputum consists mostly of mucus.]
  • Mucopurulent [The sputum consists of both mucus and pus.]
  • Purulent [The sputum consists mostly of pus.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.2], code=at0.2, itemType=ELEMENT, level=1, text=Consistency, description=The viscosity of the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thin [Low viscosity; flowing relatively freely.]
  • Thick [Relatively firm or viscous; not flowing freely.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018.1], code=at0018.1, itemType=ELEMENT, level=1, text=Colour, description=The colour of the body fluid., comment=The intent of this data element is to record either a narrative description of the colour or to select one or more codes from a value set, appropriate to the body fluid, in a template., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Clear [Appears transparent.]
  • White [Pale or off white.]
  • Grey [Shade between white and charcoal, like ash.]
  • Yellow [Shade between cream and mustard.]
  • Green [Shade between pale honeydew and olive.]
  • Rust [Shade between red and brown.]
  • Brown [Shade between light tan and chocolate.]
  • Pink [Shade between pale pink and watermelon.]
  • Black [Shade between dark grey and jet black.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0017], code=at0017, itemType=ELEMENT, level=1, text=Odour, description=The smell of the body fluid., comment=The intent of this data element is to record either a narrative description of the odour, or to code with a value set where appropriate in a template., 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[at0022], code=at0022, itemType=ELEMENT, level=1, text=Blood, description=The qualitative amount of blood observed in the body fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Absent [No blood is observed in the fluid.]
  • Slight [There is a slight amount of blood observed.]
  • Moderate [There is a moderate amount of blood observed.]
  • Large [There is a large amount of blood observed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0021.1], code=at0021.1, itemType=ELEMENT, level=1, text=Blood clots, description=Blood clots are observed within or associated with the body fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Blood clots are present.]
  • Absent [Blood clots are absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Specific findings, description=Additional structured details about the body fluid., comment=For example: inclusion of detailed CLUSTER archetypes to record details about specific fluids such as clear fluids; or inclusion of further CLUSTER.exam_body_fluid archetypes could describe components of substances such as required to describe a mixture of blood and meconium post childbirth., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.physical_properties.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the inspection 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.multimedia.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=null, 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 inspection 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], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., 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.exclusion_exam.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]