| All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of a tympanic membrane., 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, Atomica Informatics, 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
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={items=[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=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=, 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=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[at0002], code=at0002, 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 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[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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[at0.3], code=at0.3, itemType=ELEMENT, level=1, text=View, description=Description about the examiner's view of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.4::Adequate [The tympanic membrane was clearly visualised and the duration of view was sufficient; the clinical opinion of the state of the tympanic membrane is based on adequate information.]
- at0.5::Compromised [The tympanic membrane was not clearly visualised and/or the duration of view was limited; the clinical opinion of the state of the tympanic membrane is based on limited information.]
- at0.6::Total occlusion [The tympanic membrane was not visualised; a clinical opinion of the state of the tympanic membrane could not be formed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.7], code=at0.7, itemType=ELEMENT, level=1, text=Reason for occlusion, description=Narrative description of the reason for occlusion of view of the tympanic membrane., comment=For example: soft wax or a foreign body was present., 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[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Appearance, description=Category describing the appearance of the tympanic membrane., comment=In most situations, this data element would only be recorded if the tympanic membrane is intact., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.20::Translucent [The tympanic membrane appears translucent and healthy.]
- at0.21::Opaque [The tympanic membrane appears dull and opaque.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.22], code=at0.22, itemType=ELEMENT, level=1, text=Colour, description=Description of the overall colour of the tympanic membrane., comment=For example: red, bluish, or yellow., 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[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Membrane intact?, description=Is the tympanic membrane intact?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.16::Intact [The tympanic membrane appears intact.]
- at0.17::Indeterminate [It is not possible to determine if the tympanic membrane is intact or perforated.]
- at0.18::Perforated [A perforation is observed in the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.23], code=at0.23, itemType=ELEMENT, level=1, text=Surface features, description=Features observed on the surface of the tympanic membrane., comment=May be coded with an external terminology, if desired, and be expressed as multiple occurrences., 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[at0.8], code=at0.8, itemType=ELEMENT, level=1, text=Ventilation tube present?, description=Is a ventilation tube observed in the tympanic membrane?, comment=There is value in identifying the presence or absence of ventilation tubes in all examinations if ventilation tubes have previously been inserted. Please note: there is little value in recording the absence of ventilation tubes if they have never been inserted, unless it is not known if there has been previous insertion of ventilation tubes., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.9::Present [A ventilation tube is observed in the tympanic membrane or ear canal.]
- at0.10::Absent [A ventilation tube is not observed in the tympanic membrane or ear canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.11], code=at0.11, itemType=ELEMENT, level=1, text=Ventilation tube placement, description=Observed placement of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal., comment=This data element is redundant if ventilation tubes have been recorded as absent., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.12::In situ [The ventilation tube is located in situ in the tympanic membrane.]
- at0.13::Partially extruded [The ventilation tube is partially extruded from it's original position in the tympanic membrane.]
- at0.14::Extruded - remains in canal [The ventilation tube has been extruded from the tympanic membrane but is visualised within the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.24], code=at0.24, itemType=ELEMENT, level=1, text=Location of tympanosclerosis, description=Description of the location of any tympanosclerosis observed on the tympanic membrane., comment=May be coded with an external terminology, if desired, and be expressed as multiple occurrences for multiple sites., 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[at0.31], code=at0.31, itemType=ELEMENT, level=1, text=Fluid level presence, description=Finding of a fluid level behind the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.32::Present [A fluid level is observed behind the tympanic membrane.]
- at0.33::Absent [A fluid level is not observed behind the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.34], code=at0.34, itemType=ELEMENT, level=1, text=Fluid level description, description=Narrative description of the fluid level and other related features observed behind the tympanic membrane., comment=For example: presence of bubbles., 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[at0.35], code=at0.35, itemType=ELEMENT, level=1, text=Mobility, description=Description of mobility of the tympanic membrane., comment=Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobility (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.36::Immobile [Minimal or no movement of the tympanic membrane is observed when positive pressure is applied.]
- at0.37::Hypomobile [Less than 1mm inward (medial) movement of the tympanic membrane is observed when positive pressure is applied.]
- at0.38::Mobile [Crisp, inward (medial) movement (approx 1mm) when positive pressure is applied.]
- at0.39::Hypermobile [Exaggerated movement of the tympanic membrane is observed when positive pressure is applied.]
- at0.40::Indeterminate [It is not possible to determine the amount of movement of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=Position of tympanic membrane, description=Description of the position of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.26::Neutral [The tympanic membrane is in a normal, neutral position - neither bulging or retracted.]
- at0.27::Retracted [The tympanic membrane appears to be retracted.]
- at0.28::Bulging [The tympanic membrane appears to be bulging.]
- at0.29::Indeterminate [The position of the tympanic membrane is is not able to be determined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.30], code=at0.30, itemType=ELEMENT, level=1, text=Retraction description, description=Narrative description of the retraction of the tympanic membrane., 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[at0.41], code=at0.41, itemType=ELEMENT, level=1, text=Perforation description, description=Narrative description of the perforation of the tympanic membrane., 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[at0.42], code=at0.42, itemType=ELEMENT, level=1, text=Perforation size, description=Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks., comment=Many clinicians record perforations between the well defined 'pinhole' and 'subtotal' perforations using a variety of terms with inconsistent usage and definitions, such as small, medium and large. 'Intermediate' has been proposed as a means to minimise inter-clinician variability for documenting the size of all perforations falling between the 'pinhole' and 'subtotal' definitions. If more detail is required, then measurement of the perforation should be recorded., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.43::Pinhole [The perforation is the size of a pinhole.]
- at0.44::Intermediate [The perforation is larger than a pinhole but smaller than a subtotal perforation.]
- at0.45::Subtotal [The perforation is subtotal: the pars tensa is absent but the perforation does not include the annulus.]
- at0.46::Total [The tympanic membrane is essentially absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.47], code=at0.47, itemType=ELEMENT, level=1, text=Intermediate estimation, description=Qualification about the size of an intermediate perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.48::<40% [The intermediate perforation is less than 40% of the area of the tympanic membrane.]
- at0.49::>40% [The intermediate perforation is greater than 40% of the area of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.50], code=at0.50, itemType=ELEMENT, level=1, text=Length of perforation, description=Direct measurement of the longest axis of the perforation., comment=Usually measured from a photograph., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units: >=0.0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.51], code=at0.51, itemType=ELEMENT, level=1, text=Width of perforation, description=Direct measurement of the shortest axis of the perforation., comment=Usually measured from a photograph., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.52], code=at0.52, itemType=ELEMENT, level=1, text=Pars flaccida vs pars tensa?, description=Description of the region of the tympanic membrane perforation., comment=To document explicitly whether the perforation is located in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.53::Pars flaccida [The perforation is located in the pars flaccida.]
- at0.54::Pars tensa [The perforation is located in the pars tensa.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.55], code=at0.55, itemType=ELEMENT, level=1, text=Marginal vs central?, description=Location of the tympanic membrane perforation., comment=To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.56::Marginal [The perforation involves the annulus of the tympanic membrane.]
- at0.57::Central [The perforation is not involving the annulus and is bounded on all sides by the remnant of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.58], code=at0.58, itemType=ELEMENT, level=1, text=Anterior?, description=Is an anterior perforation present?, comment=To document the presence of perforation in the anterior portions of the pars tensa, which can be more difficult to manage than perforations elsewhere. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.59::Present [An anterior perforation is present in the pars tensa.]
- at0.60::Absent [An anterior perforation is not present in the pars tensa.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.61], code=at0.61, itemType=ELEMENT, level=1, text=Edge, description=Narrative description of the edge of the perforation., 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[at0004.1], code=at0004.1, 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:
openEHR-EHR-CLUSTER.sade.v0 or
openEHR-EHR-CLUSTER.exam-middle_ear.v0 or
openEHR-EHR-CLUSTER.tos.v0, 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]], description=[], context=[], activities=[], identities=[], capabilities=[], provider=[], protocol=[], content=[], source=[], credentials=[], events=[], data=[], contacts=[], ism_transition=[], details=[], relationships=[], state=[], target=[], other_participations=[]}, 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= (Cardinality: 1..*, unordered), 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=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=, 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=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[at0002], code=at0002, 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 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[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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[at0.3], code=at0.3, itemType=ELEMENT, level=1, text=View, description=Description about the examiner's view of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.4::Adequate [The tympanic membrane was clearly visualised and the duration of view was sufficient; the clinical opinion of the state of the tympanic membrane is based on adequate information.]
- at0.5::Compromised [The tympanic membrane was not clearly visualised and/or the duration of view was limited; the clinical opinion of the state of the tympanic membrane is based on limited information.]
- at0.6::Total occlusion [The tympanic membrane was not visualised; a clinical opinion of the state of the tympanic membrane could not be formed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.7], code=at0.7, itemType=ELEMENT, level=1, text=Reason for occlusion, description=Narrative description of the reason for occlusion of view of the tympanic membrane., comment=For example: soft wax or a foreign body was present., 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[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Appearance, description=Category describing the appearance of the tympanic membrane., comment=In most situations, this data element would only be recorded if the tympanic membrane is intact., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.20::Translucent [The tympanic membrane appears translucent and healthy.]
- at0.21::Opaque [The tympanic membrane appears dull and opaque.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.22], code=at0.22, itemType=ELEMENT, level=1, text=Colour, description=Description of the overall colour of the tympanic membrane., comment=For example: red, bluish, or yellow., 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[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Membrane intact?, description=Is the tympanic membrane intact?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.16::Intact [The tympanic membrane appears intact.]
- at0.17::Indeterminate [It is not possible to determine if the tympanic membrane is intact or perforated.]
- at0.18::Perforated [A perforation is observed in the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.23], code=at0.23, itemType=ELEMENT, level=1, text=Surface features, description=Features observed on the surface of the tympanic membrane., comment=May be coded with an external terminology, if desired, and be expressed as multiple occurrences., 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[at0.8], code=at0.8, itemType=ELEMENT, level=1, text=Ventilation tube present?, description=Is a ventilation tube observed in the tympanic membrane?, comment=There is value in identifying the presence or absence of ventilation tubes in all examinations if ventilation tubes have previously been inserted. Please note: there is little value in recording the absence of ventilation tubes if they have never been inserted, unless it is not known if there has been previous insertion of ventilation tubes., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.9::Present [A ventilation tube is observed in the tympanic membrane or ear canal.]
- at0.10::Absent [A ventilation tube is not observed in the tympanic membrane or ear canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.11], code=at0.11, itemType=ELEMENT, level=1, text=Ventilation tube placement, description=Observed placement of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal., comment=This data element is redundant if ventilation tubes have been recorded as absent., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.12::In situ [The ventilation tube is located in situ in the tympanic membrane.]
- at0.13::Partially extruded [The ventilation tube is partially extruded from it's original position in the tympanic membrane.]
- at0.14::Extruded - remains in canal [The ventilation tube has been extruded from the tympanic membrane but is visualised within the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.24], code=at0.24, itemType=ELEMENT, level=1, text=Location of tympanosclerosis, description=Description of the location of any tympanosclerosis observed on the tympanic membrane., comment=May be coded with an external terminology, if desired, and be expressed as multiple occurrences for multiple sites., 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[at0.31], code=at0.31, itemType=ELEMENT, level=1, text=Fluid level presence, description=Finding of a fluid level behind the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.32::Present [A fluid level is observed behind the tympanic membrane.]
- at0.33::Absent [A fluid level is not observed behind the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.34], code=at0.34, itemType=ELEMENT, level=1, text=Fluid level description, description=Narrative description of the fluid level and other related features observed behind the tympanic membrane., comment=For example: presence of bubbles., 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[at0.35], code=at0.35, itemType=ELEMENT, level=1, text=Mobility, description=Description of mobility of the tympanic membrane., comment=Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobility (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.36::Immobile [Minimal or no movement of the tympanic membrane is observed when positive pressure is applied.]
- at0.37::Hypomobile [Less than 1mm inward (medial) movement of the tympanic membrane is observed when positive pressure is applied.]
- at0.38::Mobile [Crisp, inward (medial) movement (approx 1mm) when positive pressure is applied.]
- at0.39::Hypermobile [Exaggerated movement of the tympanic membrane is observed when positive pressure is applied.]
- at0.40::Indeterminate [It is not possible to determine the amount of movement of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=Position of tympanic membrane, description=Description of the position of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.26::Neutral [The tympanic membrane is in a normal, neutral position - neither bulging or retracted.]
- at0.27::Retracted [The tympanic membrane appears to be retracted.]
- at0.28::Bulging [The tympanic membrane appears to be bulging.]
- at0.29::Indeterminate [The position of the tympanic membrane is is not able to be determined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.30], code=at0.30, itemType=ELEMENT, level=1, text=Retraction description, description=Narrative description of the retraction of the tympanic membrane., 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[at0.41], code=at0.41, itemType=ELEMENT, level=1, text=Perforation description, description=Narrative description of the perforation of the tympanic membrane., 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[at0.42], code=at0.42, itemType=ELEMENT, level=1, text=Perforation size, description=Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks., comment=Many clinicians record perforations between the well defined 'pinhole' and 'subtotal' perforations using a variety of terms with inconsistent usage and definitions, such as small, medium and large. 'Intermediate' has been proposed as a means to minimise inter-clinician variability for documenting the size of all perforations falling between the 'pinhole' and 'subtotal' definitions. If more detail is required, then measurement of the perforation should be recorded., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.43::Pinhole [The perforation is the size of a pinhole.]
- at0.44::Intermediate [The perforation is larger than a pinhole but smaller than a subtotal perforation.]
- at0.45::Subtotal [The perforation is subtotal: the pars tensa is absent but the perforation does not include the annulus.]
- at0.46::Total [The tympanic membrane is essentially absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.47], code=at0.47, itemType=ELEMENT, level=1, text=Intermediate estimation, description=Qualification about the size of an intermediate perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.48::<40% [The intermediate perforation is less than 40% of the area of the tympanic membrane.]
- at0.49::>40% [The intermediate perforation is greater than 40% of the area of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.50], code=at0.50, itemType=ELEMENT, level=1, text=Length of perforation, description=Direct measurement of the longest axis of the perforation., comment=Usually measured from a photograph., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units: >=0.0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.51], code=at0.51, itemType=ELEMENT, level=1, text=Width of perforation, description=Direct measurement of the shortest axis of the perforation., comment=Usually measured from a photograph., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.52], code=at0.52, itemType=ELEMENT, level=1, text=Pars flaccida vs pars tensa?, description=Description of the region of the tympanic membrane perforation., comment=To document explicitly whether the perforation is located in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.53::Pars flaccida [The perforation is located in the pars flaccida.]
- at0.54::Pars tensa [The perforation is located in the pars tensa.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.55], code=at0.55, itemType=ELEMENT, level=1, text=Marginal vs central?, description=Location of the tympanic membrane perforation., comment=To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.56::Marginal [The perforation involves the annulus of the tympanic membrane.]
- at0.57::Central [The perforation is not involving the annulus and is bounded on all sides by the remnant of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.58], code=at0.58, itemType=ELEMENT, level=1, text=Anterior?, description=Is an anterior perforation present?, comment=To document the presence of perforation in the anterior portions of the pars tensa, which can be more difficult to manage than perforations elsewhere. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.59::Present [An anterior perforation is present in the pars tensa.]
- at0.60::Absent [An anterior perforation is not present in the pars tensa.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.61], code=at0.61, itemType=ELEMENT, level=1, text=Edge, description=Narrative description of the edge of the perforation., 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[at0004.1], code=at0004.1, 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:
openEHR-EHR-CLUSTER.sade.v0 or
openEHR-EHR-CLUSTER.exam-middle_ear.v0 or
openEHR-EHR-CLUSTER.tos.v0, 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] |