ARCHETYPE Palpation findings (openEHR-EHR-CLUSTER.exam-palpation.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-palpation.v0
ConceptPalpation findings
DescriptionFindings observed during palpation of a body system or anatomical structure.
UseUse to record a narrative description and clinical interpretation of the findings observed during palpation of a body system or anatomical structure, identified as part of this archetype, where the findings will be recorded in isolation of other types of examination. This archetype consists only of the core palpation pattern data elements and can be expanded using other CLUSTER archetypes or specialised for palpation of specified body parts, such as: palpation of the cervix; or a digital rectal examination. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which other CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured palpation findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the palpation 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 to record other types of clinical examination. Use CLUSTER.exam or CLUSTER.exam-inspection and related specialisations for this purpose. Not to be used to record stand-alone clinical measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.head_circumference or OBSERVATION.glasgow_coma_scale. 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 palpation of a body system or anatomical structure.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-02-14
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-02-14
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, current_contact=Heather Leslie, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=278529852DE9861CC15A0DDC2F236742, build_uid=6967e335-029c-4213-817c-0c2cc2d3bb0d, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDd0f1de71-9789-4070-bcf8-87e27624c356
Language useden
Citeable Identifier1013.1.3643
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during palpation of a body system or anatomical structure., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Bjørn Næss, DIPS ASA, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Anca Heyd, DIPS ASA, Norway, originalLanguage=en, translators=Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF
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