ARCHETYPE ID | openEHR-EHR-CLUSTER.inspection_body_fluid-urine.v0 |
Concept | Inspection of urine |
Description | Findings observed during the macroscopic inspection of urine. |
Use | Use to record a narrative description, structured details and clinical interpretation about findings observed during the inspection (including odour) of urine. This archetype has been specifically designed to be used as the framework for recording details about examination of urine, with the context of the anatomical site or source of the urine will be carried in the archetypes in which it is nested, including but not limited to: - in the 'Examination findings' SLOT within many of the CLUSTER.exam family of archetypes and related inspection archetypes; - in the 'Physical properties' SLOT within the CLUSTER.specimen archetype; - in the 'Additional details' SLOT within the OBSERVATION.urinalysis, the OBSERVATION.fluid_output archetypes; and - within other OBSERVATION or CLUSTER archetypes, where clinically appropriate. 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. While this archetype will most likely be used in the context of a living subject, it is also appropriate to use in recording autopsy findings. 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 the inspection of body fluids other than urine - use the parent CLUSTER.inspection_body_fluid or other appropriate specialisations for this purpose. Not to be used to record the inspection of blood or blood clots, but only to record the presence of blood or blood clots within urine. Not to be used for recording measurements of urine output - use OBSERVATION archetypes for this purpose. For example: OBSERVATION.fluid_output. Not to be used to record details about a non-physiological fluid. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example: OBSERVATION.story and CLUSTER.symptom_sign. Not to be used to record the results of a urinalysis test - use OBSERVATION.urinalysis for this purpose. |
Purpose | To record the findings observed during the macroscopic inspection (including odour) of urine. |
References | |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-25 |
Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-25 |
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, Atomica Informatics |
Keywords | urine |
Lifecycle | in_development |
UID | 0fcb36df-75c6-4b52-87c5-ecd6f7c6e9a9 |
Language used | en |
Citeable Identifier | 1013.1.4336 |
Revision Number | 0.0.1-alpha |
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