ARCHETYPE Examination Findings - Generic (openEHR-EHR-CLUSTER.exam_generic.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_generic.v1
ConceptExamination Findings - Generic
DescriptionFindings observed during the physical examination of a specified body system or anatomical structure.
UseUse to record a narrative description of the findings observed during the physical examination of a specific body system or anatomical structure. 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 a specific body system or anatomical structure, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which can further describe specific aspects of the physical 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=1599A04562C62ACB1BABB8C4E1E2124A}
Keywordsexamination, physical, clinical, findings, exam
LifecycleCommitteeDraft
Language useden
Citeable Identifier1075.67.710
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