ARCHETYPE Examination of a wound (openEHR-EHR-CLUSTER.exam_wound.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_wound.v0
ConceptExamination of a wound
DescriptionFindings observed during the physical examination of a wound.
UseUse to record a narrative description and clinical interpretation of the findings observed during the physical examination of a wound. 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 CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. 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 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 the physical examination of a wound.
ReferencesHL7 FHIR Profile: Skin and Wound Assessment, Release 1 [cited 2019 03 18]. Available at: https://cimi.hl7.org/submissions/september_2018/skinwoundig/fullcimi/site/index.html.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-03-18
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-03-18
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=HL7 FHIR Profile: Skin and Wound Assessment, Release 1 [cited 2019 03 18]. Available at: https://cimi.hl7.org/submissions/september_2018/skinwoundig/fullcimi/site/index.html., current_contact=Heather Leslie, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=C82E52BB5404315875B646A481A4ADDD, build_uid=bfdd32bc-798f-436b-89d3-19372ff7dbeb, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID681e56d9-d0e3-4708-8281-6f827b7ed792
Language useden
Citeable Identifier1013.1.3688
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=[LOINC(2.27)::39135-9 | Wound assessment panel], archetypeConceptDescription=Findings observed during the physical examination of a wound., archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], credentials=[], description=[], relationships=[], ism_transition=[], activities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0016], code=at0016, itemType=ELEMENT, level=1, text=Wound label, description=A name or alias for the wound, so that it can be distinguished from other wounds., 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, 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[at0012], code=at0012, itemType=ELEMENT, level=1, text=Body site, description=Identification of the area of the body under examination., comment=For example: "entire body", "face" or "right cheek". If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured description of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the examination of a wound., 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[at0036], code=at0036, itemType=ELEMENT, level=1, text=Length, description=Length of the wound (longest dimension)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::39126-8 | Length of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 [in_i]
  • >=0.0 mm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0037], code=at0037, itemType=ELEMENT, level=1, text=Width, description=Width of the wound (perpendicular to longest dimension)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::39125-0 | Width of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0038], code=at0038, itemType=ELEMENT, level=1, text=Depth, description=Depth of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::39127-6 | Depth of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0039], code=at0039, itemType=ELEMENT, level=1, text=Area, description=Area of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::89260-4 | Area of wound], values=Property: Area
Units:
  • >=0.0 cm2
  • >=0.0 mm2
  • >=0.0 [sin_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0048], code=at0048, itemType=ELEMENT, level=1, text=Edge description, description=Description about the edge of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72304-9 | Edge of wound description], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0049], code=at0049, itemType=ELEMENT, level=1, text=Edge color, description=Colour of the wound edge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::39133-4 | Color of Wound edge], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0057], code=at0057, itemType=ELEMENT, level=1, text=Periwound description, description=Description of the skin surrounding the wound., comment=Multiple occurrences allow for the use of coded text to describe various aspects of the skin around the wound., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72301-5 | Description of Periwound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060], code=at0060, itemType=CLUSTER, level=1, text=Association, description=Details about factors that may be associated with the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=2..*, cardinalityText=Minimum of 2 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060]/items[at0061], code=at0061, itemType=ELEMENT, level=2, text=Factor, description=Associated factor that may causing or influencing the healing of the wound., comment=For example: a device; or pressure point., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060]/items[at0062], code=at0062, itemType=ELEMENT, level=2, text=Present or absent?, description=Is the identified factor present?, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The identified factor is observed.]
  • Absent [The identified factor is not observed.]
  • Indeterminate [It is not possible to tell if the identified factor is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054], code=at0054, itemType=CLUSTER, level=1, text=Wound bed colour, description=Details about the colour of the base of the wound., comment=Multiple occurrences of this Cluster allow for recordings of more than one colour., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054]/items[at0055], code=at0055, itemType=ELEMENT, level=2, text=Colour, description=Description of the colour of the wound base., comment=For example: red/healthy; red/hyperaemic; pink, yellow; black, brown; or grey., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::39132-6 | Color of Wound base], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054]/items[at0056], code=at0056, itemType=ELEMENT, level=2, text=Proportion, description=The proportion of the wound that is the identified colour., comment=This is the the area of the base of the wound that is a specific colour, compared to the total area of the wound bed and represented as a percentage., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=[LOINC(2.27)::89255-4 | Wound bed area identified by color/Area of wound bed], values=
  • Percent
Numerator: 0.0..100.0
Integral
Assumed value: false
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0051], code=at0051, itemType=CLUSTER, level=1, text=Wound bed appearance, description=Details about the appearance of the base of the wound., comment=Multiple occurrences of this Cluster allow for recordings of multiple discrete areas of different appearances.., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0051]/items[at0052], code=at0052, itemType=ELEMENT, level=2, text=Appearance, description=Description of the appearance of the wound base., comment=For example: necrotic; sloughing; fibrinous; eschar; or granulation tissue., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72371-8 | Appearance of Wound base], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0051]/items[at0053], code=at0053, itemType=ELEMENT, level=2, text=Proportion, description=The proportion of the wound that has the identified appearance., comment=This is the the area of the base of the wound that has a specific appearance, compared to the total area of the wound bed and represented as a percentage., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=[LOINC(2.27)::72370-0 | Area of identified wound bed appearance/Area of wound bed of Wound base], values=
  • Percent
Numerator: 0.0..100.0
Integral
Assumed value: false
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=CLUSTER, level=1, text=Internal object or structure, description=Details about the observation of any exposed body structures, devices, and/or foreign bodies visible by the naked eye in a wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Object/structure, description=Idnetification of an exposed body structure, device, and/or foreign body visible by the naked eye within the wound., comment=Coding of the visible internal structure if preferred, if possible., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::89250-5 | Device or anatomic structure visible in wound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0020], code=at0020, itemType=ELEMENT, level=2, text=Present or absent?, description=Is the object/structure present?, 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 [The identified object or structure is observed in the wound.]
  • Absent [The identified object or structure is not observed in the wound.]
  • Indeterminate [It is not possible to tell if the identified object or structure is present or absent in the wound.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the associated factor., 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[at0014]/items[at0025], code=at0025, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the associated factor, not captured in other fields., 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[at0017], code=at0017, itemType=ELEMENT, level=1, text=Tunnelling present?, description=Is tunnelling present in the wound?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[LOINC(2.27)::72298-3 | Tunneling of Wound], values=
  • Present [Tunnelling is observed in the wound.]
  • Absent [Tunnelling is not observed in the wound.]
  • Indeterminate [It is not possible to tell if a tunnel is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045], code=at0045, itemType=CLUSTER, level=1, text=Tunnelling details, description=Details about tunnelling into other tissues., comment=Multiple occurrences of this cluster will allow recording about each tunnel that leads from the wound., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045]/items[at0046], code=at0046, itemType=ELEMENT, level=2, text=Tunnel length, description=Length of an identified tunnel radiating out from the centre of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::72296-7 | Tunneling [Length] of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045]/items[at0047], code=at0047, itemType=ELEMENT, level=2, text=Direction of tunnel, description=Direction of the tunnel radiating outward from the centre of the wound, as described by a clock-face., comment=For example: one o'clock., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72297-5 | Tunneling clock position of Wound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045]/items[at0058], code=at0058, itemType=ELEMENT, level=2, text=Description, description=Narrative description of a tunnel., 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[at0013], code=at0013, itemType=ELEMENT, level=1, text=Undermining present?, description=Is undermining present in the wound?, comment=For example: color; induration; warmth; or oedema., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[LOINC(2.27)::72295-9 | Undermining of Wound], values=
  • Present [Undermining is observed in the wound.]
  • Absent [Undermining is not observed in the wound.]
  • Indeterminate [It is not possible to tell if undermining is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0059], code=at0059, itemType=ELEMENT, level=1, text=Undermining description, description=Narrative description about undermining of the whole wound., 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[at0041], code=at0041, itemType=CLUSTER, level=1, text=Undermining details, description=Details about undermining of the wound., comment=Multiple occurrences of this cluster will allow recording of the undermining occurring in different parts of the wound., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0041]/items[at0042], code=at0042, itemType=ELEMENT, level=2, text=Amount of undermining, description=Amount of tissue destruction that extends under the intact wound edge., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::72293-4 | Undermining [Length] of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0041]/items[at0044], code=at0044, itemType=ELEMENT, level=2, text=Direction of undermining, description=Direction of the undermining outward from the centre of the wound, as described by a clock-face., comment=For example: one o'clock., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72294-2 | Undermining clock position of Wound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Exudate present?, description=Is an exudate present in the wound?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[LOINC(2.27)::89259-6 | Presence of wound exudate], values=
  • Present [An exudate is observed in the wound.]
  • Absent [An exudate is not observed in the wound.]
  • Indeterminate [It is not possible to tell if an exudate is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0040], code=at0040, itemType=SLOT, level=1, text=Exudate details, description=Details about any exudate issuing from the wound., 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.exam_body_fluid.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, 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=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., 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.multimedia.v1 and specialisations Or
openEHR-EHR-CLUSTER.multimedia.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., 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[at0008], code=at0008, itemType=SLOT, level=1, text=Examination 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]], data=[], capabilities=[], state=[], context=[], events=[], source=[], content=[], target=[], details=[], provider=[], protocol=[], contacts=[]}, 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[at0016], code=at0016, itemType=ELEMENT, level=1, text=Wound label, description=A name or alias for the wound, so that it can be distinguished from other wounds., 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, 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[at0012], code=at0012, itemType=ELEMENT, level=1, text=Body site, description=Identification of the area of the body under examination., comment=For example: "entire body", "face" or "right cheek". If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured description of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the examination of a wound., 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[at0036], code=at0036, itemType=ELEMENT, level=1, text=Length, description=Length of the wound (longest dimension)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::39126-8 | Length of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 [in_i]
  • >=0.0 mm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0037], code=at0037, itemType=ELEMENT, level=1, text=Width, description=Width of the wound (perpendicular to longest dimension)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::39125-0 | Width of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0038], code=at0038, itemType=ELEMENT, level=1, text=Depth, description=Depth of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::39127-6 | Depth of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0039], code=at0039, itemType=ELEMENT, level=1, text=Area, description=Area of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::89260-4 | Area of wound], values=Property: Area
Units:
  • >=0.0 cm2
  • >=0.0 mm2
  • >=0.0 [sin_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0048], code=at0048, itemType=ELEMENT, level=1, text=Edge description, description=Description about the edge of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72304-9 | Edge of wound description], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0049], code=at0049, itemType=ELEMENT, level=1, text=Edge color, description=Colour of the wound edge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::39133-4 | Color of Wound edge], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0057], code=at0057, itemType=ELEMENT, level=1, text=Periwound description, description=Description of the skin surrounding the wound., comment=Multiple occurrences allow for the use of coded text to describe various aspects of the skin around the wound., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72301-5 | Description of Periwound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060], code=at0060, itemType=CLUSTER, level=1, text=Association, description=Details about factors that may be associated with the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=2..*, cardinalityText=Minimum of 2 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060]/items[at0061], code=at0061, itemType=ELEMENT, level=2, text=Factor, description=Associated factor that may causing or influencing the healing of the wound., comment=For example: a device; or pressure point., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060]/items[at0062], code=at0062, itemType=ELEMENT, level=2, text=Present or absent?, description=Is the identified factor present?, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The identified factor is observed.]
  • Absent [The identified factor is not observed.]
  • Indeterminate [It is not possible to tell if the identified factor is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054], code=at0054, itemType=CLUSTER, level=1, text=Wound bed colour, description=Details about the colour of the base of the wound., comment=Multiple occurrences of this Cluster allow for recordings of more than one colour., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054]/items[at0055], code=at0055, itemType=ELEMENT, level=2, text=Colour, description=Description of the colour of the wound base., comment=For example: red/healthy; red/hyperaemic; pink, yellow; black, brown; or grey., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::39132-6 | Color of Wound base], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054]/items[at0056], code=at0056, itemType=ELEMENT, level=2, text=Proportion, description=The proportion of the wound that is the identified colour., comment=This is the the area of the base of the wound that is a specific colour, compared to the total area of the wound bed and represented as a percentage., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=[LOINC(2.27)::89255-4 | Wound bed area identified by color/Area of wound bed], values=
  • Percent
Numerator: 0.0..100.0
Integral
Assumed value: false
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0051], code=at0051, itemType=CLUSTER, level=1, text=Wound bed appearance, description=Details about the appearance of the base of the wound., comment=Multiple occurrences of this Cluster allow for recordings of multiple discrete areas of different appearances.., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0051]/items[at0052], code=at0052, itemType=ELEMENT, level=2, text=Appearance, description=Description of the appearance of the wound base., comment=For example: necrotic; sloughing; fibrinous; eschar; or granulation tissue., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72371-8 | Appearance of Wound base], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0051]/items[at0053], code=at0053, itemType=ELEMENT, level=2, text=Proportion, description=The proportion of the wound that has the identified appearance., comment=This is the the area of the base of the wound that has a specific appearance, compared to the total area of the wound bed and represented as a percentage., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=[LOINC(2.27)::72370-0 | Area of identified wound bed appearance/Area of wound bed of Wound base], values=
  • Percent
Numerator: 0.0..100.0
Integral
Assumed value: false
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=CLUSTER, level=1, text=Internal object or structure, description=Details about the observation of any exposed body structures, devices, and/or foreign bodies visible by the naked eye in a wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Object/structure, description=Idnetification of an exposed body structure, device, and/or foreign body visible by the naked eye within the wound., comment=Coding of the visible internal structure if preferred, if possible., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::89250-5 | Device or anatomic structure visible in wound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0020], code=at0020, itemType=ELEMENT, level=2, text=Present or absent?, description=Is the object/structure present?, 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 [The identified object or structure is observed in the wound.]
  • Absent [The identified object or structure is not observed in the wound.]
  • Indeterminate [It is not possible to tell if the identified object or structure is present or absent in the wound.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the associated factor., 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[at0014]/items[at0025], code=at0025, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the associated factor, not captured in other fields., 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[at0017], code=at0017, itemType=ELEMENT, level=1, text=Tunnelling present?, description=Is tunnelling present in the wound?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[LOINC(2.27)::72298-3 | Tunneling of Wound], values=
  • Present [Tunnelling is observed in the wound.]
  • Absent [Tunnelling is not observed in the wound.]
  • Indeterminate [It is not possible to tell if a tunnel is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045], code=at0045, itemType=CLUSTER, level=1, text=Tunnelling details, description=Details about tunnelling into other tissues., comment=Multiple occurrences of this cluster will allow recording about each tunnel that leads from the wound., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045]/items[at0046], code=at0046, itemType=ELEMENT, level=2, text=Tunnel length, description=Length of an identified tunnel radiating out from the centre of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::72296-7 | Tunneling [Length] of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045]/items[at0047], code=at0047, itemType=ELEMENT, level=2, text=Direction of tunnel, description=Direction of the tunnel radiating outward from the centre of the wound, as described by a clock-face., comment=For example: one o'clock., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72297-5 | Tunneling clock position of Wound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045]/items[at0058], code=at0058, itemType=ELEMENT, level=2, text=Description, description=Narrative description of a tunnel., 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[at0013], code=at0013, itemType=ELEMENT, level=1, text=Undermining present?, description=Is undermining present in the wound?, comment=For example: color; induration; warmth; or oedema., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[LOINC(2.27)::72295-9 | Undermining of Wound], values=
  • Present [Undermining is observed in the wound.]
  • Absent [Undermining is not observed in the wound.]
  • Indeterminate [It is not possible to tell if undermining is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0059], code=at0059, itemType=ELEMENT, level=1, text=Undermining description, description=Narrative description about undermining of the whole wound., 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[at0041], code=at0041, itemType=CLUSTER, level=1, text=Undermining details, description=Details about undermining of the wound., comment=Multiple occurrences of this cluster will allow recording of the undermining occurring in different parts of the wound., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0041]/items[at0042], code=at0042, itemType=ELEMENT, level=2, text=Amount of undermining, description=Amount of tissue destruction that extends under the intact wound edge., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=[LOINC(2.27)::72293-4 | Undermining [Length] of Wound], values=Property: Length
Units:
  • >=0.0 cm
  • >=0.0 mm
  • >=0.0 [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0041]/items[at0044], code=at0044, itemType=ELEMENT, level=2, text=Direction of undermining, description=Direction of the undermining outward from the centre of the wound, as described by a clock-face., comment=For example: one o'clock., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[LOINC(2.27)::72294-2 | Undermining clock position of Wound], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Exudate present?, description=Is an exudate present in the wound?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[LOINC(2.27)::89259-6 | Presence of wound exudate], values=
  • Present [An exudate is observed in the wound.]
  • Absent [An exudate is not observed in the wound.]
  • Indeterminate [It is not possible to tell if an exudate is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0040], code=at0040, itemType=SLOT, level=1, text=Exudate details, description=Details about any exudate issuing from the wound., 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.exam_body_fluid.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, 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=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., 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.multimedia.v1 and specialisations Or
openEHR-EHR-CLUSTER.multimedia.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., 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[at0008], code=at0008, itemType=SLOT, level=1, text=Examination 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]