TEMPLATE Examination archetypes (Examination archetypes)

TEMPLATE ID	Examination archetypes
Concept	Examination archetypes
Description	Not Specified
Purpose	Not Specified
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1013.26.62
Root archetype id	openEHR-EHR-COMPOSITION.encounter.v1
Example template for examination archetypes	Example template for examination archetypes: Interaction, contact or care event between a subject of care and healthcare provider(s).
Physical examination findings	Physical examination findings: Findings observed during the physical examination of a subject of care.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Description	Description: Narrative description of the overall findings observed during a physical examination of a patient. May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format.
Examination findings	Examination findings: Findings observed during the physical examination of a body system or anatomical structure.
System or structure examined	System or structure examined: Identification of the XYZ under examination.
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of breasts	Examination of breasts: Findings observed during the physical examination of the breasts.
No abnormality detected	No abnormality detected: Statement that no abnormality was detected (NAD) on examination of both breasts. 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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Symmetry?	Symmetry?: Description of the appearance of symmetry of both breasts in comparison to one another.
Examination of left breast	Examination of left breast: Findings observed during the physical examination of a single breast.
Breast examined	Breast examined: Identification of the the breast under examination. Left
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of right breast	Examination of right breast: Findings observed during the physical examination of a single breast.
Breast examined	Breast examined: Identification of the the breast under examination. Right
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of the chest	Examination of the chest: Findings observed during the physical examination of the chest.
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Auscultation of the left lung	Auscultation of the left lung: Findings observed during the auscultation of the lung.
Lung examined	Lung examined: Identification of the lung under examination. If the side of the lung being examined has previously been identified in another archetype in which this archetype is nested, this data element becomes redundant. Left
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of a lung	Examination of a lung: Findings observed during the physical examination of a single lung.
Lung examined	Lung examined: Identification of the the lung under examination. Left Right
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of the heart	Examination of the heart: Findings observed during the physical examination of the heart.
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of nervous system	Examination of nervous system: Findings observed during the physical examination of the nervous system as a whole.
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the overall physical examination of the nervous system. Use this data element to incorporate the unstructured descriptions of clinical findings of the nervous sysem within existing or legacy clinical systems into an archetyped format.
Examination Findings - Pupils	Examination Findings - Pupils: Findings on physical examination of the pupils.
Description	Description: Narrative description of findings observed during a physical examination of the pupil. Use this data element to provide additional, narrative description of any data elements that are represented only by structured values.
Symmetry	Symmetry: An estimate of the equality of the size and shape of the pupils. Equal Unequal
Per Pupil	Per Pupil: Physical examination findings of an identified pupil.
Pupil Examined	Pupil Examined: Identification of the pupil under examination. Left Right Both pupils
Shape	Shape: The shape of the pupil. Normal, circular Abnormal Oval Irregular Sectoral abnormaility Teardrop Keyhole
Measured Size	Measured Size: Measured size of the pupil. 0..30 mm
Estimated Size	Estimated Size: A text description of the estimated pupil size. Pin-point pupil Constricted pupil. Normal sized pupil Dilated pupil
Direct Light Reflex	Direct Light Reflex: Pupil constricts with light shone into that eye. Present Absent Sluggish/slow (-) Normal speed (+/-) Brisk(+) Very brisk (++)
Consensual Light Reflex	Consensual Light Reflex: Findings of the consensual pupillary light reflex. Present Absent Sluggish/slow (-) Normal (+/-) Brisk (+)
Accommodation Reflex	Accommodation Reflex: Findings of the pupillary accommodation reflex. Present Absent Sluggish/slow (-) Normal (-/+) Brisk (+)
Relative Afferent Pupillary Defect	Relative Afferent Pupillary Defect: Findings of the relative afferent pupillary defect. Present Absent
Interpretation	Interpretation: Single word, phrase or brief description representing a summary of the examination findings applying to a single pupil.
Image	Image: Multimedia image taken during examination of the identified pupil.
Interpretation	Interpretation: Single word, phrase or brief description representing a summary of the examination findings applying to both puplis. Coding with a terminology is preferred, if possible. For example, SNOMED-CT\|386667005\| Pupils equal, react to light and accommodation\|.
Image	Image: Multimedia image taken during examination of both pupils.
Comment	Comment: Additional narrative about the physical examination findings of the pupil, not captured in other fields.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of cranial nerves	Examination of cranial nerves: Findings observed during the physical examination of the cranial nerves.
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Examination of the tongue	Examination of the tongue: Findings observed during the physical examination of the tongue.
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Deviation on protrusion	Deviation on protrusion: Description of deviation on protrusion. None Deviates to right Deviates to left
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Examination of the abdomen	Examination of the abdomen: Findings observed during the physical examination of the abdomen.
No abnormality detected	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	Clinical description: Narrative description of the overall findings observed during the physical examination.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the physical examination findings, not captured in other fields.
Exclusion of examination	Exclusion of examination: Positive statement to record that the physical examination, or a specified part of the physical examination, was not performed.
Examination not done	Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed.
Reason	Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints.
Interpretation	Interpretation: Single word, phrase or brief description which represents the clinical meaning and significance of the physical examination findings. Coding with a terminology is preferred, if possible. For example, 'normal examination' or 'tympanic membrane perforation'.
Comment	Comment: Additional narrative about the overall physical examination findings not captured in other fields.
State
Confounding factors	Confounding factors: Description of any incidental factors that may have contributed to the physical examination findings.