ARCHETYPE Physical Examination Findings (openEHR-EHR-OBSERVATION.exam.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.exam.v1
ConceptPhysical Examination Findings
DescriptionFindings observed during the physical examination of a subject.
UseUse to record a narrative description of the findings observed during the overall physical examination of a subject. 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. Use as a container archetype - to provide a common, queryable ENTRY archetype in which specific, detailed CLUSTER examination archetypes can be nested. Examples of CLUSTER examination archetypes include those that detail the inspection, palpation, auscultation, percussion and movement of body systems or anatomical structures.
MisuseNot to be used for recording history-taking observations - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure, OBSERVATION.body_weight, or OBSERVATION.height.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the overall physical examination of a subject, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will enable specific aspects of the physical examination to be recorded in detail.
References
Copyright© openEHR Foundation
AuthorsIme avtorja: Heather Leslie
Organizacija: Ocean Informatics
e-Pošta: heather.leslie@oceaninformatics.com
Datum izvora: 2007-11-10
Other Details LanguageIme avtorja: Heather Leslie
Organizacija: Ocean Informatics
e-Pošta: heather.leslie@oceaninformatics.com
Datum izvora: 2007-11-10
OtherDetails Language Independent{current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, MD5-CAM-1.0.1=80899BB6E9AEE27C4482EC7E74B6A755}
Keywordsexamination, physical, exam, findings, clinical
LifecycleOrganisationDraft
Language useden
Citeable Identifier1075.67.594
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Rita Apelt, Department of Health,NT, Australia
Margaret Campbell, Queensland Health, Australia
Stephen Chu, NEHTA, Australia
Margaret Cotter, AMSANT, Australia
Michelle Dowden, Miwatj Health Ngalkanbuy Health, Australia
Tim Garden, NTG Department of Health, Australia
Tanya Gardner, CAAC, Australia
Sam Heard, Ocean Informatics, Australia (Editor)
Heather Leslie, Ocean Informatics, Australia (Editor)
Ian McNicoll, Ocean Informatics, United Kingdom (Editor)
Jeremy Oats, NT Health, Australia
Steven Schatz, Department of Health (Northern Territory), Australia
Cherie Whitbread, Royal Darwin Hospital, Australia
Jo Wright, NT Dept of Health, Australia (Editor), originalLanguage=en, translators=Arabic (Syria): Mona Saleh
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