archetype (adl_version=1.4; uid=1d358227-2032-4cdd-83d7-2965308bb549) openEHR-EHR-CLUSTER.exam_lips.v0 concept [at0000] -- Examination of both lips language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Atomica Informatics"> ["email"] = <"heather.leslie@atomicainformatics.com"> ["date"] = <"2015-07-17"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording a narrative description and clinical interpretation of the findings observed during the physical examination of the lips."> use = <"Use to record a narrative description of the overall findings observed during the physical examination of the lips. This initial draft archetype consists only of the core examination pattern data elements (as per CLUSTER.exam_pattern) and will likely be expanded further over time as specific clinical requirements are identified. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_mouth archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which other CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, CLUSTER.exam_lip. 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 data not related to the physical examination of lips. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure or OBSERVATION.imaging_exam."> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"rejected"> other_contributors = <"Silje Ljosland Bakke, Bergen Hospital Trust, Norway", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom", "John Tore Valand, Haukeland Universitetssjukehus, Norway"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> ["custodian_organisation"] = <"openEHR Foundation"> ["current_contact"] = <"Heather Leslie, Atomica Informatics"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"3B0BFC27954289E9A704A86849E99FEF"> ["build_uid"] = <"6af5f09a-1fac-491c-a5db-948e27241746"> ["revision"] = <"0.0.1"> > definition CLUSTER[at0000] matches { -- Examination of both lips items cardinality matches {1..*; unordered} matches { ELEMENT[at0002] occurrences matches {0..1} matches { -- No abnormality detected value matches { DV_BOOLEAN matches { value matches {True} } } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } ELEMENT[at0009] occurrences matches {0..1} matches { -- Symmetry? value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0004] occurrences matches {0..*} matches { -- Examination findings include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam_lip(-[a-zA-Z0-9_]+)*\.v0/} } allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches { -- Multimedia representation include archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0006] occurrences matches {0..*} matches { -- Clinical interpretation value matches { DV_TEXT matches {*} } } ELEMENT[at0007] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Examination not done include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/} } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Examination of both lips"> description = <"Findings observed during the physical examination of both lips."> > ["at0002"] = < text = <"No abnormality detected"> description = <"Statement that no abnormality was detected (NAD) on physical examination."> comment = <"Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element."> > ["at0003"] = < text = <"Clinical description"> description = <"Narrative description of the overall findings observed during the physical examination."> > ["at0004"] = < text = <"Examination findings"> description = <"Structured details about the physical examination findings."> > ["at0005"] = < text = <"Multimedia representation"> description = <"Digital image, video or diagram representing the physical examination findings."> > ["at0006"] = < text = <"Clinical interpretation"> description = <"Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings."> > ["at0007"] = < text = <"Comment"> description = <"Additional narrative about the physical examination findings, not captured in other fields."> > ["at0008"] = < text = <"Examination not done"> description = <"Details to explicitly record that this examination was not performed."> > ["at0009"] = < text = <"Symmetry?"> description = <"Description of the appearance of symmetry of the lips in comparison to the other side."> > > > >