| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-vagina.v0 |
|---|---|
| Concept | Examination of the vagina |
| Description | Findings observed during the physical examination of the vagina. |
| Use | Use to record the observed findings during the physical examination of the vagina. 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. 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. |
| 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. |
| Purpose | To record the findings observed during the physical examination of the vagina. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Keisha Barwise Organisation: openEHR Foundation Email: keisha.barwise@moh.gov.jm Date originally authored: 2025-07-16 |
| Other Details Language | Author name: Keisha Barwise Organisation: openEHR Foundation Email: keisha.barwise@moh.gov.jm Date originally authored: 2025-07-16 |
| Other Details (Language Independent) |
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| Keywords | Vagina, gynaecological exam, pelvic exam, discharge, bleeding, tenderness, lesion, prolapse, inspection, palpation, speculum. |
| Lifecycle | in_development |
| UID | 3718da82-84f3-4488-b2e9-b23a03700474 |
| Language used | en |
| Citeable Identifier | 1013.1.7974 |
| Revision Number | 0.0.1-alpha |
| items | |
| 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. |
| 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. |
| 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_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| Examination findings | Examination findings: Structured details about the physical examination findings. Include: All not explicitly excluded archetypes |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Include: openEHR-EHR-CLUSTER.media_ |
| 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. |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| Discharge presence | Discharge presence: Assertion about the observed presence or absence of discharge on examination.
|
| Discharge description | Discharge description: Narrative description of discharge found on examination. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Bleeding presence | Bleeding presence: Assertion about the observed presence or absence of bleeding on examination.
|
| Bleeding description | Bleeding description: Narrative description of bleeding found on examination. |
| Bleeding details | Bleeding details: Structured details observed about bleeding. Include: All not explicitly excluded archetypes |
| Lesion details | Lesion details: Structured details observed on examination of lesions. Include: All not explicitly excluded archetypes |
| Tenderness presence | Tenderness presence: Assertion about the observed presence or absence of tenderness on examination.
|
| Tenderness description | Tenderness description: Narrative description of tenderness found on examination. |
| Tenderness details | Tenderness details: Structured details observed about tenderness. Include: All not explicitly excluded archetypes |
| Prolapse presence | Prolapse presence: Assertion about the observed presence or absence of prolaps on examination.
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| Prolapse description | Prolapse description: Narrative description of prolapse found on examination. |
| Mucosa description | Mucosa description: Narrative description of mucosa found on examination. |
| Mucosa details | Mucosa details: Structured details observed about the mucosa. Include: All not explicitly excluded archetypes |
| Foreign body presence | Foreign body presence: Assertion about the observed presence or absence of a foreign body on examination.
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| Foreign body description | Foreign body description: Narrative description of a foreign body found on examination. |
| Foreign body details | Foreign body details: Structured details observed about a foreign body. Include: All not explicitly excluded archetypes |
| Other contributors | Nicola Ewen Hall, openEHR Fellow 2025, Jamaica Heather Leslie, openEHR Foundation, Chief Clinical Information Officer |
| Translators |
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