ARCHETYPE Sensation finding (openEHR-EHR-CLUSTER.sensation_finding.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.sensation_finding.v0
ConceptSensation finding
DescriptionThe observed response to applying a light touch, pain or temperature stimulus to an identified area of skin.
UseUse to record the observed response to applying a light touch, pain or temperature stimulus to an identified area of skin, usually a dermatome or dermatome group. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetype. It can also be nested within any other relevant OBSERVATION or Physical examination-related family of CLUSTER archetypes, where clinically appropriate. In clinical scenarios requiring documentation of the sensory responses in more than one area of skin or modality, use a separate instance of this archetype for each area/modality pair tested.
MisuseNot to be used to record the sensory response to vibration applied to a bony prominence - use the CLUSTER.vibration_finding for this purpose. Not to be used to record the most caudal sensory level in response to applying a light touch, pain or temperature stimulus - use the CLUSTER.sensory_level for this purpose.
PurposeTo record the observed response to applying a light touch, pain or temperature stimulus to an identified area of skin.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2023-06-14
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2023-06-14
Other Details (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
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • MD5-CAM-1.0.1: F636088477B33F39471F2FDB1590E92F
  • Build Uid: 193cf267-3c1d-4d6d-988c-fa84a1bf4220
  • Revision: 0.0.1-alpha
Keywordsdermatome, dermatomes, limb, sensation, touch, pain, temperature, hot, cold, pinprick
Lifecyclein_development
UID31c6b858-0cbc-436a-a18d-26bde2b3dce5
Language useden
Citeable Identifier1013.1.6960
Revision Number0.0.1-alpha
items
Body siteBody site: Identification of the dermatome, or group of dermatomes or skin area being tested.
For example: C5, C5/C6, or right arm.
ModalityModality: The type of sensation tested.
Choice of:
  •  Coded Text
    • Light touch
    • Pain
    • Temperature
  •  Text
StimulusStimulus: Description of the stimulus used.
For example: testing light touch with cotton wool; or pain using a needle.
ResponseResponse: The elicited response to the stimulus.
Choice of:
  •  Ordinal
    0: Absent [No sensation is present. May be recorded as '0' or '-'.]
    1: Decreased [Sensation is present but less than considered normal. May be recorded as '+' or '1+'.]
    2: Normal [Sensation is present and considered normal. May be recorded as '++' or '2+'.]
    3: Increased [Sensation is present but more than considered normal. May be recorded as '+++' or '3+'.]
  •  Text
CommentComment: Additional narrative about the dermatomal sensory finding, not captured in other fields.
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