ARCHETYPE Examination of an external auditory canal (openEHR-EHR-CLUSTER.exam-external_auditory_canal.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-external_auditory_canal.v0
ConceptExamination of an external auditory canal
DescriptionFindings observed during the physical examination of an external auditory canal.
UseUse to record a narrative description and clinical interpretation of the findings observed during the physical examination of an external auditory canal. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-ear or OBSERVATION.exam 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, the tympanic membrane. 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 for recording data not related to other parts of the ear or middle ear - use the specific archetypes, CLUSTER.exam-ear and CLUSTER.exam-middle_ear for this purpose. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
PurposeTo record a narrative description and clinical interpretation of the findings observed during the physical examination of an external auditory canal.
ReferencesDerived from: Examination of external auditory canal, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2012 Sep 03. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1384_2 (discontinued).

Direct communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program.
Copyright© Northern Territory Department of Health (Australia), openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2012-09-03
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2012-09-03
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=Derived from: Examination of external auditory canal, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2012 Sep 03. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1384_2 (discontinued). Direct communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program., current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=9A115F4A01747388F30FB922BDA587FD, build_uid=c1c5d80f-6bc6-4321-a6b4-7e140263decf, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDbafa07d9-193a-4f46-be0f-0d1c78553329
Language useden
Citeable Identifier1013.1.3914
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of an external auditory canal., 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

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    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=Wax description, description=Narrative description of the wax findings in the external auditory canal., 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[at0.4], code=at0.4, itemType=ELEMENT, level=1, text=Canal tenderness, description=Presence of tenderness in the external auditory canal., 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 [Tenderness is noted in the external auditory canal wall.]
    • Absent [Tenderness is not noted in the external auditory canal wall.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.7], code=at0.7, itemType=ELEMENT, level=1, text=Offensive odour, description=Presence of any offensive odour originating from the external auditory canal., 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 [An offensive odour is noted as originating from the external auditory canal.]
    • Absent [No offensive odour is noted as originating from the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.10], code=at0.10, itemType=ELEMENT, level=1, text=Discharge presence, description=Presence of a discharge observed in the external auditory canal., 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 [Discharge is observed within the external auditory canal.]
    • Absent [Discharge is not observed within the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.13], code=at0.13, itemType=ELEMENT, level=1, text=Discharge type, description=Type of discharge observed in the external auditory canal or at 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=
    • Blood-stained [The discharge appears to consist mostly of blood.]
    • Haemoserous [The discharge appears to consist of both blood and clear, watery fluid.]
    • Mucoid [The discharge appears to consist mostly of a thick, mucoid substance.]
    • Mucopurulent [The discharge appears to consist of both mucous and pus.]
    • Purulent [The discharge appears to consist mostly of pus.]
    • Serous [The discharge appears to consist mostly of clear, watery fluid.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.20], code=at0.20, itemType=ELEMENT, level=1, text=Discharge amount, description=Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane 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=
    • Scant [A small amount of discharge is observed in the external auditory canal.]
    • Moderate [A moderate amount of discharge is observed in the external auditory canal.]
    • Profuse [A profuse amount of discharge is observed in the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.24], code=at0.24, itemType=ELEMENT, level=1, text=Discharge description, description=Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane 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[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=Foreign body presence, description=Presence of a foreign body in the external auditory canal., 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 [A foreign body is present in the external auditory canal.]
    • Absent [A foreign body is not present in the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.28], code=at0.28, itemType=ELEMENT, level=1, text=Foreign body location, description=Location of the foreign body within the external auditory canal., comment=This data element is redundant if a foreign body is absent from the canal., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Outer canal [The foreign body is located in the outer part of the external auditory canal.]
    • Deep canal [The foreign body is located in the deep, inner part of the external auditory canal.]
    • Middle ear [The foreign body is located within the middle ear cavity.]
    , 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.exam-tympanic_membrane.v0 or
    openEHR-EHR-CLUSTER.exam-middle_ear.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:
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    openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or
    openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations or
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    • Present [Tenderness is noted in the external auditory canal wall.]
    • Absent [Tenderness is not noted in the external auditory canal wall.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.7], code=at0.7, itemType=ELEMENT, level=1, text=Offensive odour, description=Presence of any offensive odour originating from the external auditory canal., 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 [An offensive odour is noted as originating from the external auditory canal.]
    • Absent [No offensive odour is noted as originating from the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.10], code=at0.10, itemType=ELEMENT, level=1, text=Discharge presence, description=Presence of a discharge observed in the external auditory canal., 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 [Discharge is observed within the external auditory canal.]
    • Absent [Discharge is not observed within the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.13], code=at0.13, itemType=ELEMENT, level=1, text=Discharge type, description=Type of discharge observed in the external auditory canal or at 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=
    • Blood-stained [The discharge appears to consist mostly of blood.]
    • Haemoserous [The discharge appears to consist of both blood and clear, watery fluid.]
    • Mucoid [The discharge appears to consist mostly of a thick, mucoid substance.]
    • Mucopurulent [The discharge appears to consist of both mucous and pus.]
    • Purulent [The discharge appears to consist mostly of pus.]
    • Serous [The discharge appears to consist mostly of clear, watery fluid.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.20], code=at0.20, itemType=ELEMENT, level=1, text=Discharge amount, description=Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane 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=
    • Scant [A small amount of discharge is observed in the external auditory canal.]
    • Moderate [A moderate amount of discharge is observed in the external auditory canal.]
    • Profuse [A profuse amount of discharge is observed in the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.24], code=at0.24, itemType=ELEMENT, level=1, text=Discharge description, description=Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane 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[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=Foreign body presence, description=Presence of a foreign body in the external auditory canal., 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 [A foreign body is present in the external auditory canal.]
    • Absent [A foreign body is not present in the external auditory canal.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.28], code=at0.28, itemType=ELEMENT, level=1, text=Foreign body location, description=Location of the foreign body within the external auditory canal., comment=This data element is redundant if a foreign body is absent from the canal., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Outer canal [The foreign body is located in the outer part of the external auditory canal.]
    • Deep canal [The foreign body is located in the deep, inner part of the external auditory canal.]
    • Middle ear [The foreign body is located within the middle ear cavity.]
    , 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.exam-tympanic_membrane.v0 or
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