| ARCHETYPE ID | openEHR-EHR-CLUSTER.lesions.v0 |
|---|---|
| Concept | Lesions |
| Description | Findings observed during the physical examination of lesions. |
| Use | Use to record the observed findings during the physical examination of one or more lesions. This archetype has been specifically designed to be used within CLUSTER archetypes, where clinically appropriate. 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 presence and summary characteristics of one or more lesions observed during physical examination. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Keisha Barwise Organisation: openEHR Foundation Email: keisha.barwise@openehr.org Date originally authored: 2025-07-21 |
| Other Details Language | Author name: Keisha Barwise Organisation: openEHR Foundation Email: keisha.barwise@openehr.org Date originally authored: 2025-07-21 |
| Other Details (Language Independent) |
|
| Keywords | Lesion, mass, ulcer, nodule, swelling, inspection, polyp. |
| Lifecycle | in_development |
| UID | 9272290a-50d5-4f5e-b525-e231b5e51ad8 |
| Language used | en |
| Citeable Identifier | 1013.1.7975 |
| Revision Number | 0.0.1-alpha |
| items | |
| Lesion type | Lesion type: A short descriptive name or identifier for the lesion or mass. |
| Presence | Presence: Assertion about the observed presence or absence of a lesion or mass during the examination.
|
| Number of lesions | Number of lesions: The total count of distinct lesions or masses identified. |
| Clinical descriptions | Clinical descriptions: Narrative description of the overall findings observed during the examination per lesion type. |
| Additional details | Additional details: Relevant clinical observations about the lesion type or masses that are not otherwise described. Include: All not explicitly excluded archetypes |
| Per lesion | Per lesion: Specific features or attributes that apply to this individual lesion or mass. Include: openEHR-EHR-CLUSTER.exam_ |
| Comment | Comment: Additional narrative about the findings on examination of the lesion, not captured in other fields. |
| Other contributors | Nicola Ewen Hall, openEHR Fellow 2025, Jamaica Khin Aung, Thrive Consultants, Jamaica Heather Leslie, openEHR Foundation, Chief Clinical Information Officer |
| Translators |