ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-inspection.v0 |
Concept | Inspection findings |
Description | Findings observed by direct visualisation of an anatomical structure. |
Use | Use to record a narrative description and clinical interpretation of the findings observed only by direct visualisation of a body system or anatomical structure. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. 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. |
Misuse | Not to be used when multiple modes are used simultaneously to examine a body system or anatomical structure, including palpation or auscultation. Use the CLUSTER.exam family of archetypes for this purpose. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign. |
Purpose | To record a narrative description and clinical interpretation of the findings observed by direct visualisation of a body system or anatomical structure. |
References | |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2019-02-14 |
Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2019-02-14 |
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=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics, Australia |
Keywords | |
Lifecycle | in_development |
UID | 539c40f7-e892-4048-9a69-d8c0ef213b49 |
Language used | en |
Citeable Identifier | 1246.145.2297 |
Revision Number | 0.0.1-alpha |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=[SNOMED-CT: Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) SB Bhattacharyya, Sudisa Consultancy Services, India Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Shahla Foozonkhah, Iran ministry of health and education, Iran Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor) Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør) Ingrid Heitmann, Oslo universitetssykehus HF, Norway Hilde Hollås, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Lars Ivar Mehlum, Helse Bergen HF, Norway Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Lars Morgan Karlsen, DIPS ASA, Norway Bjørn Næss, DIPS ASA, Norway Andrej Orel, Marand d.o.o., Slovenia Vladimir Pizzo, Hospital Sírio Libanês, Brazil Jussara Rotzsch, UNB, Brazil Anoop Shah, University College London, United Kingdom Line Silsand, Universitetssykehuset i Nord-Norge, Norway Norwegian Review Summary, Nasjonal IKT HF, Norway Nyree Taylor, Ocean Informatics, Australia (openEHR Editor) Rowan Thomas, St. Vincent's Hospital Melbourne, Australia Jon Tysdahl, Furst medlab AS, Norway John Tore Valand, Helse Bergen, Norway (openEHR Editor) Anca Heyd, DIPS ASA, Norway, originalLanguage=en, translators=
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