ARCHETYPE Examination of pinna (openEHR-EHR-CLUSTER.exam_pinna.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_pinna.v0
ConceptExamination of pinna
DescriptionFindings observed during the physical examination of the external structure of the ears and immediate periauricular region.
UseUse to record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of external structure of the ears and immediate periauricular region, including scars. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_ears archetype, but can also be used within the OBSERVATION.exam and 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. 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 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 - use specific OBSERVATION archetypes. For example OBSERVATION.tympanogram_226hz.
PurposeFor recording a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of external structure of the ears and immediate periauricular region, including scars.
ReferencesDerived from: Examination of Pinna, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2013 Feb 05. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1095_13 (discontinued).

Communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program.

Northern Territory Government, Department of Health: Hearing Health Program ENT Specialist Consultation Form 2011 12 07.

Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Teleotology Nurse Consultation Form 2011 12 07.

Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Audiologist Consultation Form 2011 12 07.

OATSIH: The Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (2010). Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25792800821BE8?OpenDocument.
Copyright© Northern Territory Department of Health, Australia, openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2013-02-05
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.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=Derived from: Examination of Pinna, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2013 Feb 05. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1095_13 (discontinued). Communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program. Northern Territory Government, Department of Health: Hearing Health Program ENT Specialist Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Teleotology Nurse Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Audiologist Consultation Form 2011 12 07. OATSIH: The Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (2010). Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25792800821BE8?OpenDocument., current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=4A61ED47ABEAE1BB3BC4913FA4D642F2, build_uid=a2ec9ca1-3793-425b-9ea4-67f940dd59ab, revision=0.0.1-alpha}
Keywordsexamination, physical, clinical, findings, exam, pinna, ear, external, auricle
Lifecyclein_development
UID2d313cb8-07ff-4837-9c6e-f0114e00eaab
Language useden
Citeable Identifier1013.1.3190
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of the external structure of the ears and immediate periauricular region., archetypeConceptComment=null, otherContributors=Stephen Chu, NEHTA, Australia
Harvey Coates, UWA, Australia
Marissa Cookson, Dept of Health, Australia
Kimberley Crebbin, NT Hearing Services, Australia
Kathy Currie, Northern Territory Health, Australia
Jade Frederiksen, Hearing Health Program, DoH, Australia
Sam Heard, Ocean Informatics, Australia
Paul Hickey, Hearing Health Program, Australia
Oliver Hosking, Remote Health NT, Australia
Anthony Leech, Hearing Health, Australia
Kerrie Lee, Ngaanyatjarra Health Service, Australia (Editor)
Heather Leslie, Atomica Informatics, Australia (Editor)
Ian McNicoll, Ocean Informatics UK, United Kingdom
Mark Ramjan, NT Department of Health, Australia
Kelly Simmons, Department of Health, Australia
Fiona Wake, RAHC, Australia
Christine Wigger, Menzies School of Health Research, Australia, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={details=[], identities=[], source=[], credentials=[], context=[], description=[], ism_transition=[], events=[], content=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0010], code=at0010, itemType=ELEMENT, level=1, text=Pinna examined, description=Identification of the pinna examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left pinna [Examination findings for the left pinna.]
  • Right pinna [Examination findings for the right pinna.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected on examination., comment=Record as True if no abnormality was detected on examination., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position., comment=May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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[at0015], code=at0015, itemType=CLUSTER, level=1, text=Surgical scar, description=Findings about surgical scars identified on, or related to the identified pinna., comment=The key intent of these data element is to identify the possible existence of significant middle ear surgery where this has not been previously recorded in the subject. This is a not uncommon occurrence in the remote communities managed by NT Hearing Health., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015]/items[at0019], code=at0019, itemType=ELEMENT, level=2, text=Present?, description=Is a scar present in the periaural region?, 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 [A post-surgical scar is present.]
  • Absent [A post-surgical scar is not present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015]/items[at0016], code=at0016, itemType=ELEMENT, level=2, text=Site of scar, description=Identification of the the specific anatomical structure of the pinna or related anatomical region examined., comment=Coding of the System/Stucture with a terminology is desirable, where possible., 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[at0015]/items[at0017], code=at0017, itemType=ELEMENT, level=2, text=Scar description, description=Narrative description of the scar, including likely aetiology and state of healing., 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[at0002], code=at0002, itemType=SLOT, level=1, text=Pinna details, description=Structured details of physical examination findings for the specific parts of the identified pinna or related structures., comment=For examination, associated lymph nodes or skin., 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[at0005], code=at0005, itemType=ELEMENT, level=1, text=Multimedia representation, description=Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/cgm, image/gif, image/png, image/tiff, image/jpeg, video/BT656, video/CelB, video/H261, video/H263, video/H263-1998, video/H263-2000, video/quicktime, application/pdf, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings., comment=Coding with a terminology is preferred, if possible. For example, normal examination or a specific physical finding., 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[at0022], code=at0022, itemType=SLOT, level=1, text=Exam 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]], capabilities=[], other_participations=[], contacts=[], target=[], data=[], relationships=[], state=[], protocol=[], activities=[], provider=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, 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[at0010], code=at0010, itemType=ELEMENT, level=1, text=Pinna examined, description=Identification of the pinna examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left pinna [Examination findings for the left pinna.]
  • Right pinna [Examination findings for the right pinna.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected on examination., comment=Record as True if no abnormality was detected on examination., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position., comment=May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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[at0015], code=at0015, itemType=CLUSTER, level=1, text=Surgical scar, description=Findings about surgical scars identified on, or related to the identified pinna., comment=The key intent of these data element is to identify the possible existence of significant middle ear surgery where this has not been previously recorded in the subject. This is a not uncommon occurrence in the remote communities managed by NT Hearing Health., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015]/items[at0019], code=at0019, itemType=ELEMENT, level=2, text=Present?, description=Is a scar present in the periaural region?, 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 [A post-surgical scar is present.]
  • Absent [A post-surgical scar is not present.]
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All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=ELEMENT, level=1, text=Multimedia representation, description=Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/cgm, image/gif, image/png, image/tiff, image/jpeg, video/BT656, video/CelB, video/H261, video/H263, video/H263-1998, video/H263-2000, video/quicktime, application/pdf, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings., comment=Coding with a terminology is preferred, if possible. For example, normal examination or a specific physical finding., 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[at0022], code=at0022, itemType=SLOT, level=1, text=Exam 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]