ARCHETYPE Examination of both ears (openEHR-EHR-CLUSTER.exam_ears.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_ears.v0
ConceptExamination of both ears
DescriptionFindings observed during the physical examination of both ears.
UseUse to record a narrative description of the overall findings observed during the physical examination of the ears. 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, CLUSTER.exam_tympanic_membrane, CLUSTER.exam_auditory_canal and CLUSTER.exam.pinna. 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 the ears. Not to be used to record data about measurements made during hearing assessments - use specific purpose-built OBSERVATION archetypes. For example: OBSERVATION.audiometry_result or OBSERVATION.tympanogram_226hz. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the physical examination of both ears, including comparative findings between both external ears.
ReferencesExamination of ears, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-20]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1088
Copyright© openEHR Foundation, Australian Digital Health Agency
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-02-05
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-02-05
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=Examination of ears, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-20]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1088, current_contact=Heather Leslie, Ocean Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=28435A8FA8B5D514B8D8DC3B808CB745, build_uid=05774481-9675-4df1-a906-9d4583350438, revision=0.0.1-alpha}
Keywordsexamination, physical, clinical, findings, ear, exam
Lifecyclein_development
UIDd22d9a75-6362-4209-86aa-eb77e1b18cdb
Language useden
Citeable Identifier1013.1.2874
Revision Number0.0.1-alpha
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Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway
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