| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=Example template for examination archetypes, description=Interaction, contact or care event between a subject of care and healthcare provider(s)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=1, text=Physical examination findings, description=Findings observed during the physical examination of a subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Description, description=Narrative description of the overall findings observed during a physical examination of a patient., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v0], code=at0000, itemType=CLUSTER, level=5, text=Examination findings, description=Findings observed during the physical examination of a body system or anatomical structure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=System or structure examined, description=Identification of the XYZ under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0], code=at0000, itemType=CLUSTER, level=5, text=Examination of breasts, description=Findings observed during the physical examination of the breasts., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on examination of both breasts., 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Symmetry?, description=Description of the appearance of symmetry of both breasts in comparison to one another., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of left breast'], code=at0000, itemType=CLUSTER, level=6, text=Examination of left breast, description=Findings observed during the physical examination of a single breast., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of left breast']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Breast examined, description=Identification of the the breast under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of left breast']/items[at0002], code=at0002, itemType=ELEMENT, level=7, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of left breast']/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of left breast']/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of left breast']/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of right breast'], code=at0000, itemType=CLUSTER, level=6, text=Examination of right breast, description=Findings observed during the physical examination of a single breast., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of right breast']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Breast examined, description=Identification of the the breast under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of right breast']/items[at0002], code=at0002, itemType=ELEMENT, level=7, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of right breast']/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of right breast']/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[openEHR-EHR-CLUSTER.exam_breast.v0 and name/value='Examination of right breast']/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_breasts.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0], code=at0000, itemType=CLUSTER, level=5, text=Examination of the chest, description=Findings observed during the physical examination of the chest., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.auscultation_lung.v0], code=at0000, itemType=CLUSTER, level=6, text=Auscultation of the left lung, description=Findings observed during the auscultation of the lung., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.auscultation_lung.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Lung examined, description=Identification of the lung under examination., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.auscultation_lung.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=7, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.auscultation_lung.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.auscultation_lung.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.auscultation_lung.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_lung.v0], code=at0000, itemType=CLUSTER, level=6, text=Examination of a lung, description=Findings observed during the physical examination of a single lung., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_lung.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Lung examined, description=Identification of the the lung under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_lung.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=7, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_lung.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_lung.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_lung.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_heart.v0], code=at0000, itemType=CLUSTER, level=6, text=Examination of the heart, description=Findings observed during the physical examination of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=7, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_chest.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0], code=at0000, itemType=CLUSTER, level=5, text=Examination of nervous system, description=Findings observed during the physical examination of the nervous system as a whole., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Clinical description, description=Narrative description of the overall findings observed during the overall physical examination of the nervous system., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1], code=at0000, itemType=CLUSTER, level=6, text=Examination Findings - Pupils, description=Findings on physical examination of the pupils., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0069], code=at0069, itemType=ELEMENT, level=7, text=Description, description=Narrative description of findings observed during a physical examination of the pupil., comment=Use this data element to provide additional, narrative description of any data elements that are represented only by structured values., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0071], code=at0071, itemType=ELEMENT, level=7, text=Symmetry, description=An estimate of the equality of the size and shape of the pupils., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075], code=at0075, itemType=CLUSTER, level=7, text=Per Pupil, description=Physical examination findings of an identified pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0015], code=at0015, itemType=ELEMENT, level=8, text=Pupil Examined, description=Identification of the pupil under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0005], code=at0005, itemType=ELEMENT, level=8, text=Shape, description=The shape of the pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Normal, circular
- Abnormal
- Oval
- Irregular
- Sectoral abnormaility
- Teardrop
- Keyhole
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0002], code=at0002, itemType=ELEMENT, level=8, text=Measured Size, description=Measured size of the pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..30 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0020], code=at0020, itemType=ELEMENT, level=8, text=Estimated Size, description=A text description of the estimated pupil size., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Pin-point pupil
- Constricted pupil.
- Normal sized pupil
- Dilated pupil
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0003], code=at0003, itemType=ELEMENT, level=8, text=Direct Light Reflex, description=Pupil constricts with light shone into that eye., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Present
- Absent
- Sluggish/slow (-)
- Normal speed (+/-)
- Brisk(+)
- Very brisk (++)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0004], code=at0004, itemType=ELEMENT, level=8, text=Consensual Light Reflex, description=Findings of the consensual pupillary light reflex., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Present
- Absent
- Sluggish/slow (-)
- Normal (+/-)
- Brisk (+)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0006], code=at0006, itemType=ELEMENT, level=8, text=Accommodation Reflex, description=Findings of the pupillary accommodation reflex., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Present
- Absent
- Sluggish/slow (-)
- Normal (-/+)
- Brisk (+)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0053], code=at0053, itemType=ELEMENT, level=8, text=Relative Afferent Pupillary Defect, description=Findings of the relative afferent pupillary defect., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0076], code=at0076, itemType=ELEMENT, level=8, text=Interpretation, description=Single word, phrase or brief description representing a summary of the examination findings applying to a single pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0070], code=at0070, itemType=ELEMENT, level=8, text=Image, description=Multimedia image taken during examination of the identified pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0068], code=at0068, itemType=ELEMENT, level=7, text=Interpretation, description=Single word, phrase or brief description representing a summary of the examination findings applying to both puplis., comment=Coding with a terminology is preferred, if possible. For example, SNOMED-CT|386667005| Pupils equal, react to light and accommodation|., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0077], code=at0077, itemType=ELEMENT, level=7, text=Image, description=Multimedia image taken during examination of both pupils., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the physical examination findings of the pupil, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_nervous_system.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_cranial_nerves.v0], code=at0000, itemType=CLUSTER, level=5, text=Examination of cranial nerves, description=Findings observed during the physical examination of the cranial nerves., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_cranial_nerves.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_cranial_nerves.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_cranial_nerves.v0]/items[openEHR-EHR-CLUSTER.exam_tongue.v0], code=at0000, itemType=CLUSTER, level=6, text=Examination of the tongue, description=Findings observed during the physical examination of the tongue., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_cranial_nerves.v0]/items[openEHR-EHR-CLUSTER.exam_tongue.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=7, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_cranial_nerves.v0]/items[openEHR-EHR-CLUSTER.exam_tongue.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_cranial_nerves.v0]/items[openEHR-EHR-CLUSTER.exam_tongue.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=7, text=Deviation on protrusion, description=Description of deviation on protrusion., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- None
- Deviates to right
- Deviates to left
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