ARCHETYPE Examination of the vagina (openEHR-EHR-CLUSTER.exam-vagina.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-vagina.v0
ConceptExamination of the vagina
DescriptionFindings observed during the physical examination of the vagina.
UseUse 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.
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 the vagina.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@moh.gov.jm
Date originally authored: 2025-07-16
Other Details LanguageAuthor name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@moh.gov.jm
Date originally authored: 2025-07-16
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=7B006D8C36C0896324F7A8DBF93358B0, build_uid=29a7137f-f984-4b6d-ac0d-8875c2a004de, 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}
KeywordsVagina, gynaecological exam, pelvic exam, discharge, bleeding, tenderness, lesion, prolapse, inspection, palpation, speculum.
Lifecyclein_development
UID3718da82-84f3-4488-b2e9-b23a03700474
Language useden
Citeable Identifier1013.1.7974
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of the vagina., archetypeConceptComment=null, otherContributors=Nicola Ewen Hall, openEHR Fellow 2025, Jamaica
Heather Leslie, openEHR Foundation, Chief Clinical Information Officer, originalLanguage=en, 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, Clara Calleja Vega, Servei Català de la Salut, CatSalut. Servei Català de la Salut., juliodesosa@catsalut.cat, ccalleja@catsalut.cat
  • Catalan: Laura Moral López, Sistema de Salut de Catalunya, lauramoral@catsalut.cat
    Other Contributors: Tradcrea
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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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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  • Present
  • Absent
  • Indeterminate
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  • Present
  • Absent
  • Indeterminate
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All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.12], code=at0.12, itemType=SLOT, level=1, text=Lesion details, description=Structured details observed on examination of lesions., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.13], code=at0.13, itemType=ELEMENT, level=1, text=Tenderness presence, description=Assertion about the observed presence or absence of tenderness on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.17], code=at0.17, itemType=ELEMENT, level=1, text=Tenderness description, description=Narrative description of tenderness found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.18], code=at0.18, itemType=SLOT, level=1, text=Tenderness details, description=Structured details observed about tenderness., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Prolapse presence, description=Assertion about the observed presence or absence of prolaps on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
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All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.26], code=at0.26, itemType=ELEMENT, level=1, text=Foreign body presence, description=Assertion about the observed presence or absence of a foreign body on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.30], code=at0.30, itemType=ELEMENT, level=1, text=Foreign body description, description=Narrative description of a foreign body found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.31], code=at0.31, itemType=SLOT, level=1, text=Foreign body details, description=Structured details observed about a foreign body., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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openEHR-EHR-CLUSTER.media_file.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.1], code=at0.1, itemType=ELEMENT, level=1, text=Discharge presence, description=Assertion about the observed presence or absence of discharge on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.5], code=at0.5, itemType=ELEMENT, level=1, text=Discharge description, description=Narrative description of discharge found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.6], code=at0.6, itemType=ELEMENT, level=1, text=Bleeding presence, description=Assertion about the observed presence or absence of bleeding on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.10], code=at0.10, itemType=ELEMENT, level=1, text=Bleeding description, description=Narrative description of bleeding found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.11], code=at0.11, itemType=SLOT, level=1, text=Bleeding details, description=Structured details observed about bleeding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.12], code=at0.12, itemType=SLOT, level=1, text=Lesion details, description=Structured details observed on examination of lesions., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.13], code=at0.13, itemType=ELEMENT, level=1, text=Tenderness presence, description=Assertion about the observed presence or absence of tenderness on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.17], code=at0.17, itemType=ELEMENT, level=1, text=Tenderness description, description=Narrative description of tenderness found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.18], code=at0.18, itemType=SLOT, level=1, text=Tenderness details, description=Structured details observed about tenderness., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Prolapse presence, description=Assertion about the observed presence or absence of prolaps on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.23], code=at0.23, itemType=ELEMENT, level=1, text=Prolapse description, description=Narrative description of prolapse found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.24], code=at0.24, itemType=ELEMENT, level=1, text=Mucosa description, description=Narrative description of mucosa found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.25], code=at0.25, itemType=SLOT, level=1, text=Mucosa details, description=Structured details observed about the mucosa., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.26], code=at0.26, itemType=ELEMENT, level=1, text=Foreign body presence, description=Assertion about the observed presence or absence of a foreign body on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present
  • Absent
  • Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.30], code=at0.30, itemType=ELEMENT, level=1, text=Foreign body description, description=Narrative description of a foreign body found on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.31], code=at0.31, itemType=SLOT, level=1, text=Foreign body details, description=Structured details observed about a foreign body., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]