ISO_639-1 en false 2015-07-17 Heather Leslie Atomica Informatics heather.leslie@atomicainformatics.com Silje Ljosland Bakke, Bergen Hospital Trust, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom John Tore Valand, Haukeland Universitetssjukehus, Norway rejected 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/. openEHR Foundation Heather Leslie, Atomica Informatics<heather.leslie@atomicainformatics.com> org.openehr openEHR Foundation org.openehr 3B0BFC27954289E9A704A86849E99FEF 6af5f09a-1fac-491c-a5db-948e27241746 0.0.1

ISO_639-1 en For recording a narrative description and clinical interpretation of the findings observed during the physical examination of the lips. 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. 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. © openEHR Foundation

1d358227-2032-4cdd-83d7-2965308bb549 openEHR-EHR-CLUSTER.exam_lips.v0 1.4 at0000 CLUSTER true true false false 1 1 at0000 items true true false false 1 1 ELEMENT true true false false 0 1 at0002 value true true false false 0 1 DV_BOOLEAN true true false false 1 1 value true true false false 1 1 BOOLEAN true true false false 1 1 true false ELEMENT true true false false 0 1 at0003 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0009 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0004 archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam_lip(-[a-zA-Z0-9_]+)*\.v0/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.exam_lip(-[a-zA-Z0-9_]+)*\.v0 constraint CLUSTER true false true 0 at0005 archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1 constraint ELEMENT true false true 0 at0006 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0007 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0008 archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1 constraint false false true false true 1 Examination of both lips Findings observed during the physical examination of both lips. No abnormality detected Statement that no abnormality was detected (NAD) on physical examination. Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. Clinical description Narrative description of the overall findings observed during the physical examination. Examination findings Structured details about the physical examination findings. Multimedia representation Digital image, video or diagram representing the physical examination findings. Clinical interpretation Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. Comment Additional narrative about the physical examination findings, not captured in other fields. Examination not done Details to explicitly record that this examination was not performed. Symmetry? Description of the appearance of symmetry of the lips in comparison to the other side.