| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_tympanic_membrane.v0 |
|---|---|
| Concept | Examination of tympanic membrane |
| Description | Findings observed during the physical examination of the tympanic membrane . |
| Use | Use to record a narrative description of the overall findings, structured details and clinical interpretation observed during the physical examination of the tympanic membrane. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_auditory_canal archetype, but can also be used within the OBSERVATION.exam and 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_middle_ear. 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 other parts of the ear such as the Pinna or Middle ear - use the specific archetypes, CLUSTER.exam_pinna and CLUSTER.exam_middle_ear. 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.audiogram_result. |
| Purpose | For recording a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of the tympanic membrane. |
| References | Derived from: Examination of tympanic membrane, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2012 Sep 03. Available at: hhttp://dcm.nehta.org.au/ckm#showArchetype_1013.1.1086_17 (discontinued). |
| Copyright | © Northern Territory Department of Health (Australia), openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics, Australia Email: heather.leslie@atomicainformatics.com Date originally authored: 2012-09-03 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics, Australia Email: heather.leslie@atomicainformatics.com Date originally authored: 2012-09-03 |
| Other Details (Language Independent) |
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| Keywords | inspection, ear, tympanic, perforation, drum, canal, otoscopic, examination, pneumatic, otoscopy, membrane |
| Lifecycle | rejected |
| UID | 57ac40f4-750f-4e4a-9d54-814b1febaa38 |
| Language used | en |
| Citeable Identifier | 1013.1.3189 |
| Revision Number | 0.0.1 |
| items | |
| Ear examined | Ear examined: Identification of the ear under examination. This data element may be redundant if the ear examined has been specified in the archetype in which this archetype is nested.
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| No abnormality detected | No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination of the tympanic membrane. 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 of the tympanic membrane. Use this data element to provide additional, narrative description of any data elements related to the tympanic membrane examination as a whole, that are not represented by structured values. For example: increased vascularity of the tympanic membrane. |
| View | View: Description about the examiner's view of the tympanic membrane.
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| Reason for occlusion | Reason for occlusion: Narrative description of the reason for occlusion of view of the tympanic membrane. For example, soft wax or foreign body. |
| Ventilation tube present? | Ventilation tube present?: Is a ventilation tube observed in the tympanic membrane? There is value in identifying the presence or absence of ventilation tubes in all examinations if ventilation tubes have previously been inserted. Please note: there is little value in recording the absence of ventilation tubes if they have never been inserted, unless it is not known if there has been previous insertion of ventilation tubes.
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| Ventilation tube position | Ventilation tube position: Observed position of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal. This data element is redundant if ventilation tubes have been recorded as absent.
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| Membrane intact? | Membrane intact?: Is the tympanic membrane intact?
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| Appearance | Appearance: Category describing the appearance of the tympanic membrane. In most situations, this data element would only be recorded if the tympanic membrane is intact.
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| Colour | Colour: Description of the overall colour of the tympanic membrane. For example: red, bluish, or yellow. |
| Light reflex | Light reflex: Is a normal light reflex observed? In most situations, this data element would only be recorded if the tympanic membrane is intact. A 'normal' light reflex may be described as : a complete, bright triangular area of reflected light seen in the anteroinferior portion of the tympanic membrane.
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| Surface features | Surface features: Features observed on the surface of the tympanic membrane. This data element allows multiple occurrences to enable multiple selections, if required. In most situations, this data element would only be recorded if the tympanic membrane is intact. |
| Location of tympanosclerosis | Location of tympanosclerosis: Description of the location of any tympanosclerosis observed on the tympanic membrane. May be coded with an external terminology, if desired, and be expressed as multiple occurrences for multiple sites. |
| Position of tympanic membrane | Position of tympanic membrane: Description of the position of the tympanic membrane.
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| Retraction description | Retraction description: Narrative description of the retraction of the tympanic membrane. |
| Retraction grade | Retraction grade: Description of retraction using formal classification. For example: Sade Classification or Tos Classification, typically used by ENT specialists. Include: openEHR-EHR-CLUSTER.sade.v1 and specialisations or openEHR-EHR-CLUSTER.tos.v1 and specialisations |
| Fluid level presence | Fluid level presence: Observation of a fluid level behind the tympanic membrane.
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| Fluid level description | Fluid level description: Narrative description of the fluid level and other related features observed behind the tympanic membrane. For example, presence of bubbles. |
| Mobility | Mobility: Description of mobility of the tympanic membrane. Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobility (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set.
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| Perforation details | Perforation details: Details about a perforation in the tympanic membrane. |
| Perforation description | Perforation description: Narrative description of the perforation of the tympanic membrane. |
| Estimation of size | Estimation of size: Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks. Many clinicians record perforations between the well defined 'pinhole' and 'subtotal' perforations using a variety of terms with inconsistent usage and definitions, such as small, medium and large. 'Intermediate' has been proposed as a means to minimise inter-clinician variability for documenting the size of all perforations falling between the 'pinhole' and 'subtotal' definitions. If more detail is required, then measurement of the perforation should be recorded.
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| Intermediate estimation | Intermediate estimation: Further detail about the size of an intermediate perforation.
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| Dimensions | Dimensions: Direct measurement of the size of the tympanic membrane perforation, usually using a photograph as the source for direct measurement. Include: openEHR-EHR-CLUSTER.dimensions.v1 and specialisations |
| Pars flaccida vs pars tensa? | Pars flaccida vs pars tensa?: Description of the region of the tympanic membrane perforation. To document explicitly whether the perforation is located in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant.
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| Marginal vs central? | Marginal vs central?: Location of the tympanic membrane perforation. To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant.
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| Anterior? | Anterior?: Is an anterior perforation present? To document the presence of perforation in the anterior portions of the pars tensa, which can be more difficult to manage than perforations elsewhere. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant.
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| Edge | Edge: Narrative description of the edge of the perforation. |
| Examination findings | Examination findings: Structured details about the physical examination findings. Include: All not explicitly excluded archetypes |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Both pre- and post-cleaning images to be recorded as part of the 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. Coding with a terminology is preferred, if possible. For example, normal examination or chronic otitis media. |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| 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 Stephen Chu, NEHTA, Australia Harvey Coates, UWA, Australia Marissa Cookson, Dept of Health, Australia Kimberley Crebbin, NT Hearing Services, Australia Graeme Crossland, Northern Territory, Australia Kathy Currie, Northern Territory Health, Australia Jacques de Haan, Alice Springs Hospital, Australia Jade Frederiksen, Hearing Health Program, DoH, Australia Sam Heard, Ocean Informatics, Australia (Editor) Paul Hickey, Hearing Health Program, Australia Oliver Hosking, Remote Health NT, Australia Amanda Leach, Menzies School of Health Research, Australia Anthony Leech, Hearing Health, Australia Kerrie Lee, Ngaanyatjarra Health Service, Australia Heather Leslie, Ocean Informatics, Australia (Editor) Ian McNicoll, Ocean Informatics, United Kingdom Hemi Patel, Royal Darwin Hospital, Australia Mark Ramjan, NT Department of Health, Australia Fiona Wake, RAHC, Australia Christine Wigger, Menzies School of Health Research, Australia |
| Translators |