ARCHETYPE Examination of both eyes (openEHR-EHR-CLUSTER.exam-both_eyes.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-both_eyes.v0
ConceptExamination of both eyes
DescriptionFindings observed during the physical examination of both eyes.
UseUse to record a narrative description and clinical interpretation of the findings observed during the physical examination of both eyes, including comparative findings between both eyes. Information on which device used can be recorded in the element 'Device details' in the OBSERVATION.exam, in the element 'Procedure detail' in the ACTION.procedure, or in an equivalent element in an appropriate ENTRY or ACTION archetype. 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, for example CLUSTER.exam-eye. 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 both eyes, including comparative findings between both eyes.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-06-23
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-06-23
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Ocean Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=2AF480F958F1EE2EC0D17E90AADCBF8A, build_uid=31c15669-8b94-4107-8d89-e50cffa8e5b5, revision=0.0.1-alpha}
Keywordsexamination, physical, clinical, findings, exam, eye
Lifecyclein_development
UID3d88d646-da7d-4782-985e-a76f5319d0c9
Language useden
Citeable Identifier1013.1.3777
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of both eyes., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
SB Bhattacharyya, Sudisa Consultancy Services, India
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Hilde Hollås, DIPS ASA, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Ivar Mehlum, Helse Bergen HF, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Ocean Health Systems, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Lars Morgan Karlsen, DIPS ASA, Norway
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Jussara Rotzsch, UNB, Brazil
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia (openEHR Editor)
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Jon Tysdahl, Furst medlab AS, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators=Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF
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  • Both eyes [Both eyes examined.]
    [SNOMED-CT::40638003] (Structure of both eyes (body structure))

Assumed value: Both eyes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=1, text=(No abnormality detected), description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin 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}
Runtime name constraint:
  • PERL [Pupils are equal and reactive to light.]
  • PERLA [Pupils are equal and reactive to light and accomodation.]
  • No abnormality detected [Commonly used statement no abnormality was detected (NAD) on examination of both eyes.]
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openEHR-EHR-CLUSTER.multimedia.v1 and specialisations Or
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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=at0000.1, 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[at0001.1], code=at0001.1, 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=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Both eyes [Both eyes examined.]
    [SNOMED-CT::40638003] (Structure of both eyes (body structure))

Assumed value: Both eyes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=1, text=(No abnormality detected), description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin 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}
Runtime name constraint:
  • PERL [Pupils are equal and reactive to light.]
  • PERLA [Pupils are equal and reactive to light and accomodation.]
  • No abnormality detected [Commonly used statement no abnormality was detected (NAD) on examination of both eyes.]
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openEHR-EHR-CLUSTER.multimedia.v1 and specialisations Or
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