| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_pinna.v0 |
|---|---|
| Concept | Examination of pinna |
| Description | Findings observed during the physical examination of the external structure of the ears and immediate periauricular region. |
| Use | Use 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. |
| Misuse | 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 - use specific OBSERVATION archetypes. For example OBSERVATION.tympanogram_226hz. |
| Purpose | For 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. |
| 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. |
| 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: 2013-02-05 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics, Australia Email: heather.leslie@atomicainformatics.com Date originally authored: 2013-02-05 |
| Other Details (Language Independent) |
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| Keywords | examination, physical, clinical, findings, exam, pinna, ear, external, auricle |
| Lifecycle | rejected |
| UID | 2d313cb8-07ff-4837-9c6e-f0114e00eaab |
| Language used | en |
| Citeable Identifier | 1013.1.3190 |
| Revision Number | 0.0.1 |
| items | |
| Pinna examined | Pinna examined: Identification of the pinna examined.
|
| No abnormality detected | No abnormality detected: Statement that no abnormality was detected on examination. Record as True if no abnormality was detected on examination. Allowed values: {true} |
| Clinical description | Clinical description: Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position. 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. |
| Surgical scar | Surgical scar: Findings about surgical scars identified on, or related to the identified pinna. 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. |
| Present? | Present?: Is a scar present in the periaural region?
|
| Site of scar | Site of scar: Identification of the the specific anatomical structure of the pinna or related anatomical region examined. Coding of the System/Stucture with a terminology is desirable, where possible. |
| Scar description | Scar description: Narrative description of the scar, including likely aetiology and state of healing. |
| Pinna details | Pinna details: Structured details of physical examination findings for the specific parts of the identified pinna or related structures. For examination, associated lymph nodes or skin. Include: All not explicitly excluded archetypes |
| Multimedia representation | Multimedia representation: Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure. 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 |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings. Coding with a terminology is preferred, if possible. For example, normal examination or a specific physical finding. |
| Exam not done | Exam not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | 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 |
| Translators |