ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-inspection-rectum.v0 |
Concept | Inspection of the rectum |
Description | Findings observed by direct visualisation of the rectum. |
Use | Use to record a narrative description and clinical interpretation of the findings observed by direct visualisation of the rectum, for example during a proctoscopy, sigmoidoscopy or colonoscopy examination. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the 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. 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. |
Misuse | Not to be used to record details about the palpation of the rectum. Use CLUSTER.exam-palpation-rectum for this purpose. Not to be used when multiple modes are used simultaneously to examine a body system or anatomical structure, including palpation or auscultation. Use the CLUSTER.exam family of archetypes 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. |
Purpose | To record a narrative description and clinical interpretation of the findings observed by direct visualisation of the rectum. |
References | |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-09-17 |
Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-09-17 |
OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics, Australia |
Keywords | |
Lifecycle | in_development |
UID | 581934a4-9cb5-4314-90b8-72bcbc6516b4 |
Language used | en |
Citeable Identifier | 1013.1.3984 |
Revision Number | 0.0.1-alpha |
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