ARCHETYPE Examination of bleeding (openEHR-EHR-CLUSTER.bleeding_findings.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.bleeding_findings.v0
ConceptExamination of bleeding
DescriptionFindings related to observation of bleeding.
UseUse to record the observed findings related to bleeding during a physical examination, such as in an inspection or palpation of the rectum or other relevant anatomical sites. This archetype has been specifically designed to be used in the ‘Examination detail’ SLOT within the OBSERVATION.exam archetype, but can also be used within other ENTRY or CLUSTER archetypes where clinically appropriate, such as CLUSTER.exam-rectum.v0 or CLUSTER.exam-vagina.v0. Interpretation of the bleeding findings, such as ‘Bright red bleeding likely from distal source’ or ‘Scant altered blood of uncertain origin’, 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 narrative descriptions of bleeding within existing or legacy clinical systems into an archetyped format, using the ‘Clinical description’ data element.
MisuseNot to be used for recording clinical history, such as a patient's reported episodes of bleeding – use OBSERVATION.story or CLUSTER.symptom_sign for this purpose. Not to be used for quantifying blood loss over time or measuring blood as a type of fluid output – use OBSERVATION.fluid_output-blood.v0 for that purpose, especially when the focus is on the volume or rate of blood loss (e.g. postoperative drainage, menstrual flow, or hemorrhage in critical care).
PurposeTo record the observed characteristics of bleeding during a physical examination.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@openehr.org
Date originally authored: 2025-07-14
Other Details LanguageAuthor name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@openehr.org
Date originally authored: 2025-07-14
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, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=571BE0D7E01944A25E6F3A52C0B291E3, build_uid=1ccc6b38-e6c5-4509-b509-62fa81ed2797, revision=0.0.1-alpha}
KeywordsBleeding, hemorrhage, rectal bleeding, physical examination, clinical finding, observation, blood loss.
Lifecyclein_development
UID4048235c-0619-42f9-bf53-4fed49d29679
Language useden
Citeable Identifier1013.1.7978
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings related to observation of bleeding., archetypeConceptComment=null, otherContributors=Khin Aung, THRIVE Consultancy, Jamaica
Nicola Ewen Hall, openEHR Clinical Fellow 2025, Jamaica
Heather Leslie, openEHR Foundation, CCIO, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={state=[], protocol=[], identities=[], ism_transition=[], activities=[], relationships=[], contacts=[], data=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Body site, description=Identification of the body site of the bleeding., comment=If the body site is identified in the 'Structured body site' SLOT or in another archetype in which this archetype is nested, this data element may be redundant., 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[at0017], code=at0017, itemType=SLOT, level=1, text=Structured body site, description=Structured anatomical location of the bleeding., comment=If the body site is identified in the 'Body site' element or in another archetype in which this archetype is nested, this data element may be redundant., 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=Presence, description=Assertion about the observed presence or absence of bleeding., 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[at0005], code=at0005, itemType=ELEMENT, level=1, text=Description, description=Narrative description of observed bleeding., 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[at0006], code=at0006, itemType=ELEMENT, level=1, text=Source, description=The apparent origin of the bleeding if identifiable., comment=For example: from lesion, from rectal mucosa, diffuse., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Colour, description=The observed colour of the blood present 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[at0015], code=at0015, itemType=ELEMENT, level=1, text=Physical state, description=Describes the physical attributes of observed bleeding., comment=For example: liquid, clotted., 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=ELEMENT, level=1, text=Amount, description=The estimated volume of blood present., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • None
    • Trace amount
    • Small amount
    • Moderate amount
    • Large amount
    • Rectum filled with blood
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0016], code=at0016, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the observed bleeding, 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]], events=[], context=[], capabilities=[], content=[], details=[], other_participations=[], provider=[], credentials=[], source=[], description=[], target=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Body site, description=Identification of the body site of the bleeding., comment=If the body site is identified in the 'Structured body site' SLOT or in another archetype in which this archetype is nested, this data element may be redundant., 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[at0017], code=at0017, itemType=SLOT, level=1, text=Structured body site, description=Structured anatomical location of the bleeding., comment=If the body site is identified in the 'Body site' element or in another archetype in which this archetype is nested, this data element may be redundant., 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=Presence, description=Assertion about the observed presence or absence of bleeding., 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[at0005], code=at0005, itemType=ELEMENT, level=1, text=Description, description=Narrative description of observed bleeding., 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[at0006], code=at0006, itemType=ELEMENT, level=1, text=Source, description=The apparent origin of the bleeding if identifiable., comment=For example: from lesion, from rectal mucosa, diffuse., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Colour, description=The observed colour of the blood present 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[at0015], code=at0015, itemType=ELEMENT, level=1, text=Physical state, description=Describes the physical attributes of observed bleeding., comment=For example: liquid, clotted., 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=ELEMENT, level=1, text=Amount, description=The estimated volume of blood present., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • None
    • Trace amount
    • Small amount
    • Moderate amount
    • Large amount
    • Rectum filled with blood
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0016], code=at0016, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the observed bleeding, 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]], minIndents={}, termBindingRetrievalErrorMessage=null]