ARCHETYPE Examination findings (openEHR-EHR-CLUSTER.exam.v2)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam.v2
ConceptExamination findings
DescriptionFindings observed during the physical examination of a body system or anatomical structure.
UseUse to record the observed findings during the physical examination of a body system or anatomical structure. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the "Procedure detail" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Specialisations of this archetype can be used to record examination findings for identified body systems or anatomical structures. If there is no appropriate specialisation available, use this archetype and identify the system or structure being examined using the 'System or structure examined' data element and the location on the body using the 'Body site' data element or the 'Structured body site' SLOT. Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element. 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.
MisuseNot 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 for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose.
PurposeTo record the findings observed during the physical examination of a body system or anatomical structure.
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, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=D431E7E5B4C4ACEE31E2289C853A4DED, build_uid=4f914639-0324-4cd8-a0a1-5c6316fe3b66, 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=2.0.1}
Keywords
Lifecyclepublished
UID7bed0e4b-3603-4a0a-8f20-75b80d81be9b
Language useden
Citeable Identifier1013.1.6153
Revision Number2.0.1
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=[SNOMED-CT::5880005 | Physical examination], archetypeConceptDescription=Findings observed during the physical examination of a body system or anatomical structure., 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=German: Nina Schewe, Medizinische Hochschule Hannover, schewe.nina@mh-hannover.de
Swedish: Erik Sundvall, Region Östergötland + Linköping University, erik.sundvall@regionostergotland.se
Norwegian Bokmål: Silje Ljosland Bakke, Vebjørn Arntzen, Nasjonal IKT HF, Oslo University Hospital, varntzen@ous-hf.no
Portuguese (Brazil): Adriana Kitajima, Hospital Alemão Oswaldo Cruz - HAOC, adrianakitajima@gmail.com
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