ARCHETYPE Examination of sputum (openEHR-EHR-CLUSTER.exam_sputum.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_sputum.v0
ConceptExamination of sputum
DescriptionFindings observed during the examination of sputum.
UseUse to record a narrative description, structured details and clinical interpretation about the findings observed during examination of sputum, which could occur during routine clinical observations or as part of a physical examination. This archetype has been designed to record the examination findings of sputum being observed. It is assumed that the option to record whether sputum is present/absent or if a cough is productive/unproductive will be captured in the relevant parent archetype. This archetype has been designed to be used within: - the 'Examination findings' SLOT in the OBSERVATION.exam and related CLUSTER archetypes; - the OBSERVATION.fluid_output to describe the sputum being measured; or - the OBSERVATION.laboratory_test to desctibe physical properties about a sputum sample/specimen. It can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate.
MisuseNot to be used for recording measurements of sputum volume - use OBSERVATION.fluid_output for this purpose. Not to be used to record details about saliva.
PurposeTo record the findings observed during the examination of sputum.
ReferencesDerived from Examination of body fluid, Draft archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-05-03]. Available from: http://www.openehr.org/ckm/#showArchetype_1013.1.2255.
Copyright© openEHR Foundation
AuthorsAuthor name: Nyree Taylor
Organisation: Ocean Health Systems
Email: nyree.taylor@oceanhealthsystems.com
Date originally authored: 2017-05-01
Other Details LanguageAuthor name: Nyree Taylor
Organisation: Ocean Health Systems
Email: nyree.taylor@oceanhealthsystems.com
Date originally authored: 2017-05-01
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, references=Derived from Examination of body fluid, Draft archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-05-03]. Available from: http://www.openehr.org/ckm/#showArchetype_1013.1.2255., current_contact=Nyree Taylor, Ocean Health Systems, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=16B6D98DC75891FAA410176C190C3803, build_uid=5bc22ed8-f478-43c2-b857-975962ccfe0f, revision=0.0.1-alpha}
Keywordssputum, phlegm
Lifecyclein_development
UIDf19f4a02-64c0-48be-88ef-b1cfc83d7dce
Language useden
Citeable Identifier1013.1.2841
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the examination of sputum. , archetypeConceptComment=null, otherContributors=CKCM Team, Alberta Health Services, Canada
Heather Leslie, Ocean Health Systems, Australia, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={details=[], identities=[], source=[], credentials=[], context=[], description=[], ism_transition=[], events=[], content=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description about the sputum., 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[at0003], code=at0003, itemType=ELEMENT, level=1, text=Type, description=Type of sputum, categorised by the major components., 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[at0008], code=at0008, itemType=ELEMENT, level=1, text=Colour, description=The overall colour 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=
  • 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[at0022], code=at0022, itemType=ELEMENT, level=1, text=Consistency, description=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[at0025], code=at0025, itemType=ELEMENT, level=1, text=Odour, description=Narrative description of the smell., 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[at0026], code=at0026, itemType=ELEMENT, level=1, text=Blood presence, description=Sputum contains visible blood., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • None [The sputum contains no visible blood.]
  • Blood streaked [The sputum contains fine streaks of blood.]
  • Patchy [The sputum contains irregular areas of blood.]
  • Uniform [The sputum has an overall pink/red appearance due to blood.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0043], code=at0043, itemType=ELEMENT, level=1, text=Age of blood, description=Indication of the freshness of the blood present., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Fresh blood [The sputum contains bright red blood.]
  • Old blood [The sputum contains dark red to black blood.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0031], code=at0031, itemType=ELEMENT, level=1, text=Blood clot presence, description=Sputum contains coagulated blood., 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 [The sputum contains blood clots.]
  • Absent [The sputum does not contain blood clots.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0034], code=at0034, itemType=ELEMENT, level=1, text=Blood description, description=Narrative description of visible blood., 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[at0047], code=at0047, itemType=CLUSTER, level=1, text=Other findings, description=Other identified findings in the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=2, text=Finding, description=Identified finding in 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=
  • Mucus plug [Collection of abnormally thick mucus.]
  • Foreign body [Abnormal, non-physiological object.]
  • Froth [Small air bubbles.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0047]/items[at0019], code=at0019, itemType=ELEMENT, level=2, text=Presence, description=The identified finding visible in 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=
  • Present [The identified finding is observed in the sputum.]
  • Absent [The identified finding is not observed in the sputum.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0047]/items[at0035], code=at0035, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the identified finding., 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[at0036], code=at0036, itemType=SLOT, level=1, text=Additional findings, description=Additional structured details about the examination of the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0037], code=at0037, itemType=SLOT, level=1, text=Mulitmedia representation, description=Digital image, video or diagram representing 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=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0038], code=at0038, 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[at0039], code=at0039, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the examination of the sputum, 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[at0040], code=at0040, 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:
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  • 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[at0008], code=at0008, itemType=ELEMENT, level=1, text=Colour, description=The overall colour 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=
  • 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[at0022], code=at0022, itemType=ELEMENT, level=1, text=Consistency, description=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[at0025], code=at0025, itemType=ELEMENT, level=1, text=Odour, description=Narrative description of the smell., 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[at0026], code=at0026, itemType=ELEMENT, level=1, text=Blood presence, description=Sputum contains visible blood., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • None [The sputum contains no visible blood.]
  • Blood streaked [The sputum contains fine streaks of blood.]
  • Patchy [The sputum contains irregular areas of blood.]
  • Uniform [The sputum has an overall pink/red appearance due to blood.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0043], code=at0043, itemType=ELEMENT, level=1, text=Age of blood, description=Indication of the freshness of the blood present., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Fresh blood [The sputum contains bright red blood.]
  • Old blood [The sputum contains dark red to black blood.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0031], code=at0031, itemType=ELEMENT, level=1, text=Blood clot presence, description=Sputum contains coagulated blood., 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 [The sputum contains blood clots.]
  • Absent [The sputum does not contain blood clots.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0034], code=at0034, itemType=ELEMENT, level=1, text=Blood description, description=Narrative description of visible blood., 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[at0047], code=at0047, itemType=CLUSTER, level=1, text=Other findings, description=Other identified findings in the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=2, text=Finding, description=Identified finding in 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=
  • Mucus plug [Collection of abnormally thick mucus.]
  • Foreign body [Abnormal, non-physiological object.]
  • Froth [Small air bubbles.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0047]/items[at0019], code=at0019, itemType=ELEMENT, level=2, text=Presence, description=The identified finding visible in 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=
  • Present [The identified finding is observed in the sputum.]
  • Absent [The identified finding is not observed in the sputum.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0047]/items[at0035], code=at0035, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the identified finding., 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[at0036], code=at0036, itemType=SLOT, level=1, text=Additional findings, description=Additional structured details about the examination of the sputum., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0037], code=at0037, itemType=SLOT, level=1, text=Mulitmedia representation, description=Digital image, video or diagram representing 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=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0038], code=at0038, 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[at0039], code=at0039, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the examination of the sputum, 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[at0040], code=at0040, 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:
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