| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-rectum.v0 |
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| Concept | Examination of the rectum |
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| Description | Findings observed during the physical examination of the rectum. |
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| Use | Use to record the observed findings during the physical examination of the rectum.
This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element.
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. |
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| Misuse | 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 for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose. |
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| Purpose | To record the findings observed during the physical examination of the rectum. |
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| References | |
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| Copyright | © openEHR Foundation |
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| Authors | Author name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@openehr.org
Date originally authored: 2025-07-08
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| Other Details Language | Author name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@openehr.org
Date originally authored: 2025-07-08
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| 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
- Current Contact: Heather Leslie, Atomica Informatics, Australia
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: 24C7EA9AED19AE532FC5BC038FB4F833
- Build Uid: d5c2c83a-e328-4c1f-befe-38a7f4169d15
- 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 https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.
- Revision: 0.0.1-alpha
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| Keywords | Rectal exam, DRE, rectum, palpation, inspection, lesion, bleeding, mucosa, feces, foreign body. |
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| Lifecycle | in_development |
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| UID | c21ccb97-e3aa-4ff3-9101-7b97d14e09ba |
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| Language used | en |
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| Citeable Identifier | 1013.1.7955 |
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| Revision Number | 0.0.1-alpha |
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| items | |
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| System or structure examined | System or structure examined: Identification of the examined body system or anatomical structure.
Coding of the system or structure examined with a terminology is preferred, where possible. |
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| Body site | Body site: Identification of the area of the body under examination.
For example examination of a specific area of skin. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant. |
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| Structured body site | Structured body site: A structured description of the area of the body under examination.
If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant.
Include:
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.v2 and specialisations |
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| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
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| Examination findings | Examination findings: Structured details about the physical examination findings.
Include:
All not explicitly excluded archetypes |
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| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings.
Include:
openEHR-EHR-CLUSTER.media_file.v1 and specialisations |
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| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. |
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| Lesions | Lesions: Findings related to any palpable or visible lesion or mass found within the rectum on examination. |
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| Lesion type | Lesion type: A short descriptive name or identifier for the lesion or mass.
For example: ulcer, polyp, nodule, erosion, tumour. |
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| Presence | Presence: Assertion about the observed presence or absence of a lesion or mass during the examination.
- at0.49::Present
- at0.50::Absent
- at0.51::Indeterminate
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| Number of lesions | Number of lesions: The total count of distinct lesions or masses identified. |
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| Clinical description | Clinical description: Narrative description of the overall findings observed during the examination per lesion type. |
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| Per lesion details | Per lesion details: Specific features or attributes that apply to this individual lesion or mass.
Include:
openEHR-EHR-CLUSTER.exam_lesion.v0 |
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| Additional details | Additional details: Other relevant clinical observations about the lesion type or masses that are not otherwise described.
Include:
All not explicitly excluded archetypes |
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| Comment | Comment: Additional narrative about the findings on examination of the lesion, not captured in other fields. |
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| Mucosa | Mucosa: Findings related to the appearance and integrity of the rectal mucosa found on examination.
Include:
All not explicitly excluded archetypes |
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| Bleeding | Bleeding: Findings related to blood identified in the rectum. |
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| Presence | Presence: Assertion about the observed presence or absence of bleeding in the rectum.
- at0.34::Present
- at0.35::Absent
- at0.54::Indeterminate
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| Description | Description: Narrative description of observed bleeding. |
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| Source | Source: The apparent origin of the bleeding if identifiable.
For example: from lesion, from rectal mucosa, diffuse. |
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| Colour | Colour: The observed colour of the blood present.
For example: bright red (fresh), dark red, black. |
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| Physical state | Physical state: Describes the physical attributes of the blood in the rectum.
For example: liquid, clotted.
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| Amount | Amount: The estimated volume of blood present.
Choice of:
 Coded Text
- at0.43::None
- at0.44::Trace amount
- at0.45::Small amount
- at0.46::Moderate amount
- at0.47::Large amount
- at0.48::Rectum filled with blood
 Text
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| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
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| Faecal loading | Faecal loading: Assessment of amount of faecal material within the rectum.
For example: none, mild, moderate, severe. |
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| Faeces | Faeces: Documentation of the observed characteristics of stool present during the examination.
Include:
.* or
openEHR-EHR-CLUSTER.exam_faeces.v0 |
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| Foreign object | Foreign object: Findings of any non-biological or unexpected item found within the rectum during examination.
Include:
All not explicitly excluded archetypes |
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| Examination not done | Examination not done: Details to explicitly record that this examination was not performed.
Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations |
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| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
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| Other contributors | Nicola Ewen Hall, openEHR Fellow 2025 Jamaica
Khin Aung, Jamaica
Heather Leslie, openEHR Foundation, CCIO |
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| Translators | - German: Nina Schewe, Natalia Strauch, Darin Leonhardt, Medizinische Hochschule Hannover, PLRI für medizinische Informatik/ Medizinische Hochschule, schewe.nina@mh-hannover.de, Strauch.Natalia@mh-hannover.de, leonhardt.darin@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
- Greek: Erasmia Partafylla, Sigmasoft, c.partafylla@sigmasoft.gr
- Spanish (Spain): Julio de Sosa, Servei Català de la Salut, juliodesosa@catsalut.cat
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