ARCHETYPE Examination Findings - Ears (openEHR-EHR-CLUSTER.exam_ears.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_ears.v1
ConceptExamination Findings - Ears
DescriptionFindings observed during the physical examination of the ears.
UseUse to record a narrative description of the overall findings observed during the physical examination of the ears. Use the related CLUSTER archetypes - for example, CLUSTER.tympanogram and CLUSTER.pinna - to record detailed examination findings of specific aspects of the physical examination and findings for a specific ear. 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.
MisuseNot 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 - 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 physical examination of the ears, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which can further describe specific aspects of the ear examination in more detail.
References
Copyright© openEHR Foundation
AuthorsIme avtorja: Heather Leslie
Organizacija: Ocean Informatics
e-Pošta: heather.leslie@oceaninformatics.com
Datum izvora: 2013-02-05
Other Details LanguageIme avtorja: Heather Leslie
Organizacija: Ocean Informatics
e-Pošta: heather.leslie@oceaninformatics.com
Datum izvora: 2013-02-05
OtherDetails Language Independent{current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, MD5-CAM-1.0.1=FEDB468EB9F5EE04B228A3E8F2B7749A}
Keywordsexamination, physical, clinical, findings, ear, exam
LifecycleCommitteeDraft
Language useden
Citeable Identifier1075.67.703
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openEHR-EHR-CLUSTER.exam_pinna.v1 ali
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openEHR-EHR-CLUSTER.exam_pinna.v1 ali
openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical Interpretation, description=Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings., comment=Coding with a terminology is preferred, if possible. For example, normal examination or a specific physical finding., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=ELEMENT, level=1, text=Multimedia Representation, description=Digital image or video taken, or a diagram drawn, during the physical examination of the ears., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/cgm, image/gif, image/png, image/tiff, image/jpeg, video/BT656, video/CelB, video/H261, video/H263, video/H263-1998, video/H263-2000, video/quicktime, application/pdf, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]