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 of care.
UseUse to record details about findings on physical examination of the subject of care. This may include a narrative description of the findings, a framework in which to nest detailed CLUSTER examination archetypes, and a clinical interpretation of the findings. Examples of detailed CLUSTER examination archetypes include those that describe inspection, palpation, auscultation, percussion and movement of body systems or anatomical structures, such as CLUSTER.exam_pupils. Narrative descriptions of clinical findings from existing clinical systems may be captured using the 'Description' data element. Clinicians may sometimes want to record a summative phrase such as 'chronic otitis media' as an Interpretation of the physical examination. In the context of the physical examination archetype this should only be understood as 'physical signs are consistent with chronic otitis media'. While the summative phrase may appear to represent a diagnosis, safe and consistent querying requires a diagnosis to be recorded using the EVALUATION.problem_diagnosis archetype, even if the phrases are identical.
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 details about findings on physical examination of the subject of care.
References
Copyright© openEHR Foundation, Nasjonal IKT HF
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-11-10
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-11-10
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Nasjonal IKT, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=no.nasjonalikt, original_publisher=Nasjonal IKT, custodian_namespace=no.nasjonalikt, MD5-CAM-1.0.1=61D18256DA550BBFD431F41EF7307BE0, build_uid=495be8df-5a53-4755-8323-21de4602ea35, revision=1.1.4}
Keywordsexamination, physical, exam, findings, clinical
Lifecyclepublished
UID8ec2d367-1d40-4e57-bf8b-4dde81132a64
Language useden
Citeable Identifier1246.145.1287
Revision Number1.1.4
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of a subject of care., archetypeConceptComment=null, otherContributors=Sheryl Alexander, NT Department of Health, Australia
Tomas Alme, DIPS, Norway
Nadim Anani, Karolinska Institutet, Sweden
Rita Apelt, Department of Health,NT, Australia
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway
Margaret Campbell, Queensland Health, Australia
Rong Chen, Cambio Healthcare Systems, Sweden
B Christensen, HUS, Norway
Stephen Chu, Queensland Health, Australia
Margaret Cotter, AMSANT, Australia
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Michelle Dowden, Miwatj Health Ngalkanbuy Health, Australia
Samo Drnovsek, Marand ltd, Slovenia
Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)
Tim Garden, NTG Department of Health, Australia
Tanya Gardner, CAAC, Australia
Sam Heard, Ocean Informatics, Australia (Editor)
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Anca Heyd, DIPS ASA, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Russell Leftwich, Russell B Leftwich MD, United States
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Hallvard Lærum, Oslo Universitetssykehus HF, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Bjørn Næss, DIPS ASA, Norway
Jeremy Oats, NT Health, Australia
Anne Pauline Anderssen, Helse Nord RHF, Norway
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Steven Schatz, Department of Health (Northern Territory), Australia
Anoop Shah, University College London, United Kingdom
Line Sæle, Nasjonal IKT, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Cherie Whitbread, Royal Darwin Hospital, Australia
Jo Wright, NT Dept of Health, Australia (Editor)
Lin Zhang, BIPH, China, originalLanguage=en, translators=
  • German: Nina Schewe, Medizinische Hochschule Hannover, schewe.nina@mh-hannover.de
  • Swedish: Sofia Janstad, SLL, sofia.lang-janstad@sll.se
  • Norwegian Bokmål: Lars Bitsch-Larsen and Einar Fosse, John Tore Valand, Vebjørn Arntzen, Haukeland University Hospital Bergen, Norway; UNN HF Centre for Integrated Care and Telemedicine, Helse Bergen, Oslo University Hospital, lbla@helse-bergen.no; Einar.Fosse@unn.no, john.tore.valand@helse-vest-ikt.no, varntzen@ous-hf.no, MD, DEAA, MBA, specialist in tropical medic
  • Spanish (Argentina): Edgardo Vazquez, VinculoMedico, Medical Doctor
  • Portuguese (Brazil): Adriana Kitajima, Core Consulting, adriana.kitajima@coreconsulting.com.br
  • Slovenian: Uroš Rajkovič, Biljana Prinčič, Anđela Pavlović, Slovenia, Better, andjela.pavlovic@better.care
    Other Contributors: Anđela Pavlović, andjela.pavlovic@better.care, Better, Slovenia
  • Arabic (Syria): Mona Saleh
  • Chinese (PRC): Lin Zhang, BIPH, linforest@163.com, ?
  • Spanish (Spain): Pablo Pazos, CaboLabs, Computer Engineer
  • Catalan: Julio de Sosa, Servei Català de la Salut, juliodesosa@catsalut.cat
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={provider=[], target=[], capabilities=[], other_participations=[], content=[], identities=[], details=[], credentials=[], ism_transition=[], relationships=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, 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=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=SLOT, level=4, text=Examination detail, description=Structured details of the physical examination., comment=Detailed clinical findings will be recorded as CLUSTER archetypes which can be nested within this SLOT to represent the fractal nature of clinical examination and allow for variation in clinician's requirements for examination documentation. For example: CLUSTER.palpation_of_uterus, CLUSTER.palpation_of_cervix and CLUSTER.palpation_of_fetus can be nested in this slot or within each other to represent the specific requirements of clinicians working in the obstetric domains - content, priorities and level of detail will differ depending on clinical context, professional background and specialty., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Interpretation, description=Single word, phrase or brief description which 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 'tympanic membrane perforation'., 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=/data[at0001]/events[at0002]/data[at0003]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the overall physical examination findings not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], context=[], state=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0009]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Confounding factors, description=Description of any incidental factors that may have contributed to 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=/data[at0001]/events[at0002]/state[at0009]/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Position, description=The body position of the subject during the examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], description=[], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, 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=null, extendedValues=null]], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0007]/items[at0010], code=at0010, itemType=SLOT, level=2, text=Device Details, description=Details about any device used during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0007]/items[at0012], code=at0012, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], contacts=[], source=[], items=[], activities=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], state=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/state[at0009], code=at0009, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0007], code=at0007, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0007]/items[at0010], code=at0010, itemType=SLOT, level=2, text=Device Details, description=Details about any device used during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0007]/items[at0012], code=at0012, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]